Provider First Line Business Practice Location Address: 
2919 GRANITE HOLLOW ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SANDY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84092-4217
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-733-0200
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/16/2007