Provider First Line Business Practice Location Address:
3980 S 700 E
Provider Second Line Business Practice Location Address:
SUITE 21
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:
84107-2188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-268-8053
Provider Business Practice Location Address Fax Number:
801-268-3247
Provider Enumeration Date:
08/14/2012