Provider First Line Business Practice Location Address:
1875 UNIVERSITY AVE S UNIT 1
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:
99709-4906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-328-0875
Provider Business Practice Location Address Fax Number:
907-328-0865
Provider Enumeration Date:
07/18/2005