Provider First Line Business Practice Location Address:
163 S SR 112 HWY STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84029-5585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-264-4164
Provider Business Practice Location Address Fax Number:
435-264-4264
Provider Enumeration Date:
05/24/2025