Provider First Line Business Practice Location Address:
40 W. CACHE VALLEY BLVD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-787-8207
Provider Business Practice Location Address Fax Number:
435-787-8253
Provider Enumeration Date:
09/14/2006