Provider First Line Business Practice Location Address: 
48 S 2500 W STE 220
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HURRICANE
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84737-3380
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
435-574-9604
    Provider Business Practice Location Address Fax Number: 
866-543-3497
    Provider Enumeration Date: 
12/19/2018