Provider First Line Business Practice Location Address:
1100 N 55TH ST UNIT 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58203-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-550-9985
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2026