Provider First Line Business Practice Location Address:
88 W CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-4538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-553-4130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2008