Provider First Line Business Practice Location Address: 
747 S PARADISE CANYON RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CEDAR CITY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84720-3576
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
435-586-9991
    Provider Business Practice Location Address Fax Number: 
435-586-9965
    Provider Enumeration Date: 
02/12/2007