Provider First Line Business Practice Location Address:
1656 W 1500 S
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:
84104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-977-3732
Provider Business Practice Location Address Fax Number:
801-977-3751
Provider Enumeration Date:
10/25/2005