Provider First Line Business Practice Location Address:
3102 S UNIVERSITY DRIVE
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:
58103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-293-7750
Provider Business Practice Location Address Fax Number:
701-293-5845
Provider Enumeration Date:
06/14/2005