Provider First Line Business Practice Location Address:
1141 E 3900 S
Provider Second Line Business Practice Location Address:
A-170
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:
84124-1215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-270-6538
Provider Business Practice Location Address Fax Number:
801-284-4991
Provider Enumeration Date:
12/13/2005