Provider First Line Business Practice Location Address:
1815 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
SUITE 3
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:
701-237-3583
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2006