Provider First Line Business Practice Location Address:
4000 17TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-775-0641
Provider Business Practice Location Address Fax Number:
701-746-9328
Provider Enumeration Date:
08/30/2006