Provider First Line Business Practice Location Address:
825 28TH ST. S STE A
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-1245
Provider Business Practice Location Address Fax Number:
701-232-0813
Provider Enumeration Date:
11/25/2014