Provider First Line Business Practice Location Address:
3611 LINCOLN ST S STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58104-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-298-7778
Provider Business Practice Location Address Fax Number:
701-532-1297
Provider Enumeration Date:
09/27/2006