Provider First Line Business Practice Location Address:
1408 19TH AVE.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-451-6682
Provider Business Practice Location Address Fax Number:
907-459-3922
Provider Enumeration Date:
06/26/2006