Provider First Line Business Practice Location Address:
510 4TH ST S
Provider Second Line Business Practice Location Address:
PRAIRIE ST JOHNS
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-476-7239
Provider Business Practice Location Address Fax Number:
701-280-5798
Provider Enumeration Date:
09/07/2006