Provider First Line Business Practice Location Address:
3750 32ND AVE S
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-5998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-361-8482
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2009