Provider First Line Business Practice Location Address:
1308 23RD ST S
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:
701-297-7540
Provider Business Practice Location Address Fax Number:
701-297-6439
Provider Enumeration Date:
07/24/2006