Provider First Line Business Practice Location Address:
1451 44 AVE S
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-746-8414
Provider Business Practice Location Address Fax Number:
701-746-8422
Provider Enumeration Date:
09/07/2007