Provider First Line Business Practice Location Address:
1550 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-1918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-0990
Provider Business Practice Location Address Fax Number:
435-753-1969
Provider Enumeration Date:
05/23/2007