Provider First Line Business Practice Location Address:
96 S. MAIN #2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRAIM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-283-5559
Provider Business Practice Location Address Fax Number:
435-283-5559
Provider Enumeration Date:
06/29/2006