Provider First Line Business Practice Location Address:
18050 121ST AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES LACS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58733-9418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-720-0695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2026