Provider First Line Business Practice Location Address:
2101 ELM ST N
Provider Second Line Business Practice Location Address:
130R
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-3241
Provider Business Practice Location Address Fax Number:
701-239-3721
Provider Enumeration Date:
06/27/2006