Provider First Line Business Practice Location Address:
5670 38TH AVE S UNIT B
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:
58104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-566-5455
Provider Business Practice Location Address Fax Number:
701-566-5454
Provider Enumeration Date:
07/09/2010