Provider First Line Business Practice Location Address:
1383 21ST AVE N
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-237-3517
Provider Business Practice Location Address Fax Number:
701-293-9718
Provider Enumeration Date:
01/30/2013