Provider First Line Business Practice Location Address:
84 PRAIRIEWOOD DR S
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:
58103-4609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-361-6957
Provider Business Practice Location Address Fax Number:
701-237-4955
Provider Enumeration Date:
07/12/2006