Provider First Line Business Practice Location Address: 
2901 BARANOF AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KETCHIKAN
    Provider Business Practice Location Address State Name: 
AK
    Provider Business Practice Location Address Postal Code: 
99901-5765
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-225-9090
    Provider Business Practice Location Address Fax Number: 
907-225-9001
    Provider Enumeration Date: 
02/20/2007