Provider First Line Business Practice Location Address:
1405 KELLUM ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-4189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-562-0560
Provider Business Practice Location Address Fax Number:
907-562-1617
Provider Enumeration Date:
08/01/2012