Provider First Line Business Practice Location Address:
1050 E SOUTH TEMPLE
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:
84102-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-350-4593
Provider Business Practice Location Address Fax Number:
801-350-4483
Provider Enumeration Date:
08/22/2014