Provider First Line Business Practice Location Address:
1324 23RD ST S
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-3702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-237-5616
Provider Business Practice Location Address Fax Number:
701-271-8813
Provider Enumeration Date:
10/29/2008