Provider First Line Business Practice Location Address:
3011 25TH ST S
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-280-0088
Provider Business Practice Location Address Fax Number:
701-293-5602
Provider Enumeration Date:
12/31/2013