Provider First Line Business Practice Location Address:
4450 31ST AVE S
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-5433
Provider Business Practice Location Address Fax Number:
701-364-5431
Provider Enumeration Date:
05/08/2006