Provider First Line Business Practice Location Address:
3120 25TH ST S STE X
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-234-9768
Provider Business Practice Location Address Fax Number:
701-293-1510
Provider Enumeration Date:
07/21/2006