Provider First Line Business Practice Location Address:
134 W MAIN ST
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-2504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-375-4240
Provider Business Practice Location Address Fax Number:
801-375-4241
Provider Enumeration Date:
02/02/2013