Provider First Line Business Practice Location Address:
1398 E LUCK LN
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:
84106-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-463-2478
Provider Business Practice Location Address Fax Number:
801-486-0961
Provider Enumeration Date:
05/31/2006