Provider First Line Business Practice Location Address:
119 MAIN STREET SE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAMOURE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58458-0007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-883-5464
Provider Business Practice Location Address Fax Number:
701-883-5464
Provider Enumeration Date:
10/02/2014