Provider First Line Business Practice Location Address:
653 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84025-3645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-644-9244
Provider Business Practice Location Address Fax Number:
801-451-9802
Provider Enumeration Date:
10/28/2005