Provider First Line Business Practice Location Address:
2025 SOUTH 1300 EAST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-487-7991
Provider Business Practice Location Address Fax Number:
801-487-6818
Provider Enumeration Date:
12/04/2006