Provider First Line Business Practice Location Address:
1015 HOSPITAL RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BELCOURT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58316-0160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-477-0428
Provider Business Practice Location Address Fax Number:
701-477-0488
Provider Enumeration Date:
10/18/2006