Provider First Line Business Practice Location Address:
4541 52ND AVE S
Provider Second Line Business Practice Location Address:
SUITE 100
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:
701-552-6578
Provider Business Practice Location Address Fax Number:
701-380-5115
Provider Enumeration Date:
09/01/2010