Provider First Line Business Practice Location Address:
1217 HIGHWAY 85 SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58627-9433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-443-5416
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2025