Provider First Line Business Practice Location Address:
1955 S 1300 E
Provider Second Line Business Practice Location Address:
SUITE #1
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:
84105-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-487-5755
Provider Business Practice Location Address Fax Number:
801-484-5567
Provider Enumeration Date:
01/06/2012