Provider First Line Business Practice Location Address:
1407 24TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-6761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-240-7173
Provider Business Practice Location Address Fax Number:
701-775-8677
Provider Enumeration Date:
08/11/2008