Provider First Line Business Practice Location Address:
3788 55TH AVE S STE 205
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:
58104-5588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-205-4847
Provider Business Practice Location Address Fax Number:
701-540-0441
Provider Enumeration Date:
01/20/2026