Provider First Line Business Practice Location Address:
30 S 2000 E
Provider Second Line Business Practice Location Address:
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:
84112-5820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-587-9254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2026