Provider First Line Business Practice Location Address:
2850 UPTOWN WAY S APT 407
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:
58104-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-220-4467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2026