Provider First Line Business Practice Location Address:
1621 UNIVERSITY DR S APT 230
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:
58103-0005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
929-632-6428
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2026