Provider First Line Business Practice Location Address: 
7430 S. CREEK RD.
    Provider Second Line Business Practice Location Address: 
STE 104
    Provider Business Practice Location Address City Name: 
SANDY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84093-6160
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-981-8795
    Provider Business Practice Location Address Fax Number: 
801-987-8051
    Provider Enumeration Date: 
11/30/2006