Provider First Line Business Practice Location Address:
535 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE 207B
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-4728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-455-0250
Provider Business Practice Location Address Fax Number:
907-455-0250
Provider Enumeration Date:
12/08/2006