Provider First Line Business Practice Location Address:
547 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-723-2144
Provider Business Practice Location Address Fax Number:
435-723-4760
Provider Enumeration Date:
05/24/2012