Provider First Line Business Practice Location Address:
15 3RD AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERTHOLD
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-721-7316
Provider Business Practice Location Address Fax Number:
701-453-3299
Provider Enumeration Date:
04/17/2007