Provider First Line Business Practice Location Address:
100 SO 4TH ST
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-237-5787
Provider Business Practice Location Address Fax Number:
701-237-4337
Provider Enumeration Date:
03/15/2010