Provider First Line Business Practice Location Address:
1839 I ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS AFB
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58205-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-747-5382
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2025