Provider First Line Business Practice Location Address:
4153 12 TH AVE. NORTH SUITE 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:
58102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-373-8504
Provider Business Practice Location Address Fax Number:
701-373-8506
Provider Enumeration Date:
09/04/2009