Provider First Line Business Practice Location Address: 
702 E SOUTH TEMPLE STE 209
    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: 
84102-1795
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-359-8282
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/18/2007