Provider First Line Business Practice Location Address:
1169 W HIGHWAY 40
Provider Second Line Business Practice Location Address:
SUITE # C
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-781-2729
Provider Business Practice Location Address Fax Number:
435-781-2719
Provider Enumeration Date:
05/09/2007