Provider First Line Business Practice Location Address: 
98 N 1100 E STE 102
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AMERICAN FORK
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84003-2940
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-492-2550
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/23/2011