Provider First Line Business Practice Location Address:
1030 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-3050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-723-4500
Provider Business Practice Location Address Fax Number:
435-723-4504
Provider Enumeration Date:
05/10/2011