Provider First Line Business Practice Location Address:
225 WENDELL ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-455-4135
Provider Business Practice Location Address Fax Number:
907-455-4115
Provider Enumeration Date:
05/22/2007