Provider First Line Business Practice Location Address:
4040 42ND ST S STE K
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:
58104-4353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-773-4903
Provider Business Practice Location Address Fax Number:
701-922-9269
Provider Enumeration Date:
12/12/2025