Provider First Line Business Practice Location Address:
660 S 200 E
Provider Second Line Business Practice Location Address:
#250
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:
84111-3835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-359-2256
Provider Business Practice Location Address Fax Number:
801-364-4392
Provider Enumeration Date:
10/16/2012