Provider First Line Business Practice Location Address: 
106 LINCOLN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SITKA
    Provider Business Practice Location Address State Name: 
AK
    Provider Business Practice Location Address Postal Code: 
99835-7540
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-747-8666
    Provider Business Practice Location Address Fax Number: 
907-966-3979
    Provider Enumeration Date: 
02/14/2007