Provider First Line Business Practice Location Address: 
1274 S US HIGHWAY 189
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HEBER CITY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84032-5512
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
435-654-6250
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/16/2011