Provider First Line Business Practice Location Address:
260 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-723-8841
Provider Business Practice Location Address Fax Number:
435-734-9567
Provider Enumeration Date:
08/05/2006