Provider First Line Business Practice Location Address: 
9520 N WOLVERINE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PALMER
    Provider Business Practice Location Address State Name: 
AK
    Provider Business Practice Location Address Postal Code: 
99645-8734
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-745-8117
    Provider Business Practice Location Address Fax Number: 
907-745-8194
    Provider Enumeration Date: 
01/11/2008