Provider First Line Business Practice Location Address:
1867 AIRPORT WAY
Provider Second Line Business Practice Location Address:
STE 130B
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-4056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-452-2178
Provider Business Practice Location Address Fax Number:
907-452-3524
Provider Enumeration Date:
11/22/2006