Provider First Line Business Practice Location Address:
464 N 300 E
Provider Second Line Business Practice Location Address:
BASEMENT
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-650-8362
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2011