Provider First Line Business Practice Location Address:
100 4TH STR S
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-235-6075
Provider Business Practice Location Address Fax Number:
701-235-0140
Provider Enumeration Date:
10/02/2006