Provider First Line Business Practice Location Address:
200 S CENTRAL CAMPUS DR
Provider Second Line Business Practice Location Address:
ROOM 156
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84112-9149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-587-3363
Provider Business Practice Location Address Fax Number:
801-236-8043
Provider Enumeration Date:
10/12/2006