Provider First Line Business Practice Location Address: 
1640 COWLES ST
    Provider Second Line Business Practice Location Address: 
SUITE 1
    Provider Business Practice Location Address City Name: 
FAIRBANKS
    Provider Business Practice Location Address State Name: 
AK
    Provider Business Practice Location Address Postal Code: 
99701-5925
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-452-4768
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/23/2015