Provider First Line Business Practice Location Address:
87 LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNDERWOOD
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-442-3148
Provider Business Practice Location Address Fax Number:
701-442-3414
Provider Enumeration Date:
10/17/2005