Provider First Line Business Practice Location Address: 
6952 HIGH TECH DR
    Provider Second Line Business Practice Location Address: 
STE A
    Provider Business Practice Location Address City Name: 
MIDVALE
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84047-3766
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-261-5100
    Provider Business Practice Location Address Fax Number: 
801-713-0565
    Provider Enumeration Date: 
08/30/2006