Provider First Line Business Practice Location Address:
1260 E VINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-262-7455
Provider Business Practice Location Address Fax Number:
801-288-2672
Provider Enumeration Date:
08/17/2006