Provider First Line Business Practice Location Address:
2249 S 34TH ST APT 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-8806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-779-2660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2026