Provider First Line Business Practice Location Address:
4556 40TH AVENUE SOUTH
Provider Second Line Business Practice Location Address:
SUITE 130
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:
701-234-8860
Provider Business Practice Location Address Fax Number:
701-234-8924
Provider Enumeration Date:
09/20/2006