Provider First Line Business Practice Location Address:
120 W CACHE VALLEY BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-7563
Provider Business Practice Location Address Fax Number:
453-753-0886
Provider Enumeration Date:
09/20/2006