Provider First Line Business Practice Location Address:
3758 UNIVERSITY AVE S
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:
99709-4658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-374-6213
Provider Business Practice Location Address Fax Number:
907-474-3821
Provider Enumeration Date:
06/08/2005