Provider First Line Business Practice Location Address:
3242 20TH ST S
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-893-2639
Provider Business Practice Location Address Fax Number:
701-893-2638
Provider Enumeration Date:
10/11/2006