Provider First Line Business Practice Location Address:
524 4TH AVE NE UNIT 19
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEVILS LAKE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-662-7052
Provider Business Practice Location Address Fax Number:
701-662-3360
Provider Enumeration Date:
11/16/2006