Provider First Line Business Practice Location Address:
2025 S 1300 E
Provider Second Line Business Practice Location Address:
SUITE 1
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:
84105-3698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-485-8192
Provider Business Practice Location Address Fax Number:
801-487-6818
Provider Enumeration Date:
11/22/2006