Provider First Line Business Practice Location Address:
984 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-723-0329
Provider Business Practice Location Address Fax Number:
435-723-0429
Provider Enumeration Date:
06/06/2007