Provider First Line Business Practice Location Address:
1815 UNIVERSITY DR S
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:
58103-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-239-4710
Provider Business Practice Location Address Fax Number:
701-239-4719
Provider Enumeration Date:
08/15/2007