Provider First Line Business Practice Location Address: 
327 E 1300 S
    Provider Second Line Business Practice Location Address: 
APT 2
    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: 
84102
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
925-389-4679
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/19/2019