Provider First Line Business Practice Location Address:
2812 17TH AVE S
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-4048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-780-1401
Provider Business Practice Location Address Fax Number:
701-780-1404
Provider Enumeration Date:
06/28/2005