Provider First Line Business Practice Location Address: 
4600 S. HIGHLAND DRIVE
    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: 
84117
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-272-1892
    Provider Business Practice Location Address Fax Number: 
801-284-2960
    Provider Enumeration Date: 
05/19/2009