Provider First Line Business Practice Location Address:
148 S CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY CITY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-845-1421
Provider Business Practice Location Address Fax Number:
701-845-4167
Provider Enumeration Date:
10/15/2010