Provider First Line Business Practice Location Address:
100 1ST AVENUE SOUTHWEST
Provider Second Line Business Practice Location Address:
OMEGA CITY PLAZA
Provider Business Practice Location Address City Name:
LAMOURE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58458-0686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-883-5048
Provider Business Practice Location Address Fax Number:
701-883-5067
Provider Enumeration Date:
08/07/2006