Provider First Line Business Practice Location Address:
3402 13TH AVE S
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-234-0939
Provider Business Practice Location Address Fax Number:
701-234-9442
Provider Enumeration Date:
08/24/2006