Provider First Line Business Practice Location Address:
1222 WELL ST STE 2
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:
99701-2881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-309-0528
Provider Business Practice Location Address Fax Number:
907-313-2103
Provider Enumeration Date:
07/31/2026