Provider First Line Business Practice Location Address:
117 C AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPHAM
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-768-2925
Provider Business Practice Location Address Fax Number:
701-768-2925
Provider Enumeration Date:
05/30/2007