Provider First Line Business Practice Location Address:
3431 4TH AVE SW
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-2227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-298-8108
Provider Business Practice Location Address Fax Number:
701-297-7901
Provider Enumeration Date:
02/28/2007