Provider First Line Business Practice Location Address:
3212 14TH AVENUE SOUTH, SUITE 2
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:
58103-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-2662
Provider Business Practice Location Address Fax Number:
701-232-9588
Provider Enumeration Date:
04/22/2010