Provider First Line Business Practice Location Address:
3523 45TH STREET SOUTH
Provider Second Line Business Practice Location Address:
SUITE 100, OFFICE 119
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:
701-212-3449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2025