Provider First Line Business Practice Location Address: 
718 E EMERSON AVE
    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: 
84105-2217
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
925-596-0978
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/01/2020