Provider First Line Business Practice Location Address:
59 COLLEGE RD
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-455-4611
Provider Business Practice Location Address Fax Number:
907-374-8303
Provider Enumeration Date:
12/21/2006