Provider First Line Business Practice Location Address: 
246 E FIDDLERS CANYON RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CEDAR CITY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84721-9776
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
901-488-2787
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/21/2014