Provider First Line Business Practice Location Address:
1330 18TH AVE 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:
58103-4852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-8558
Provider Business Practice Location Address Fax Number:
701-255-3922
Provider Enumeration Date:
02/24/2026