Provider First Line Business Practice Location Address: 
7779 JORDAN LANDING BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WEST JORDAN
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84084-1975
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-316-0050
    Provider Business Practice Location Address Fax Number: 
801-616-0050
    Provider Enumeration Date: 
06/20/2011