Provider First Line Business Practice Location Address: 
3400 LATOUCHE ST
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
ANCHORAGE
    Provider Business Practice Location Address State Name: 
AK
    Provider Business Practice Location Address Postal Code: 
99508-4208
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
907-561-1777
    Provider Business Practice Location Address Fax Number: 
907-561-2157
    Provider Enumeration Date: 
02/20/2007