Provider First Line Business Practice Location Address:
1197 A SOUTH COLUMBIA ROAD
Provider Second Line Business Practice Location Address:
SUITE 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:
701-775-4751
Provider Business Practice Location Address Fax Number:
701-746-4931
Provider Enumeration Date:
06/29/2007