Provider First Line Business Practice Location Address:
8TH AVE AND C ST
Provider Second Line Business Practice Location Address:
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:
84143-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-4384
Provider Business Practice Location Address Fax Number:
801-507-4398
Provider Enumeration Date:
05/11/2021