Provider First Line Business Practice Location Address:
1910 42ND ST S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-4416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-365-0507
Provider Business Practice Location Address Fax Number:
701-365-0009
Provider Enumeration Date:
06/05/2013