Provider First Line Business Practice Location Address: 
102 10TH AVE
    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: 
99701-5003
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-759-7697
    Provider Business Practice Location Address Fax Number: 
907-600-5065
    Provider Enumeration Date: 
06/22/2022