Provider First Line Business Practice Location Address:
215 SOUTH 10TH EAST
Provider Second Line Business Practice Location Address:
SUITE A
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:
801-328-4173
Provider Business Practice Location Address Fax Number:
801-322-3995
Provider Enumeration Date:
12/29/2008