Provider First Line Business Practice Location Address: 
1711 GOLD DR 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: 
58103-6416
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
701-451-9417
    Provider Business Practice Location Address Fax Number: 
701-298-0066
    Provider Enumeration Date: 
06/09/2016