Provider First Line Business Practice Location Address:
1621 UNIVERSITY DR S STE 227
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:
58103-4164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-371-6166
Provider Business Practice Location Address Fax Number:
866-666-5079
Provider Enumeration Date:
01/30/2023