Provider First Line Business Practice Location Address: 
1820 WALNUT ST E STE 5
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DEVILS LAKE
    Provider Business Practice Location Address State Name: 
ND
    Provider Business Practice Location Address Postal Code: 
58301-3411
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
701-662-4913
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/09/2015