Provider First Line Business Practice Location Address: 
8170 55TH AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEHR
    Provider Business Practice Location Address State Name: 
ND
    Provider Business Practice Location Address Postal Code: 
58460-9160
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
701-269-0384
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/09/2021