Provider First Line Business Practice Location Address:
2050 CRIPPLE CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99709-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-451-0661
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2006