Provider First Line Business Practice Location Address:
293 S MAIN 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:
84321-5203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-4133
Provider Business Practice Location Address Fax Number:
435-753-7364
Provider Enumeration Date:
12/27/2012