Provider First Line Business Practice Location Address:
130 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84025-3518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-451-2842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2006