Provider First Line Business Practice Location Address: 
GEORGE A. SMITH FIELD HOUSE
    Provider Second Line Business Practice Location Address: 
FIELD HOUSE DR
    Provider Business Practice Location Address City Name: 
PROVO
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84604
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-422-2145
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/01/2023