Provider First Line Business Practice Location Address:
542 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 234
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-4714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-456-4524
Provider Business Practice Location Address Fax Number:
907-456-5524
Provider Enumeration Date:
11/21/2006