Provider First Line Business Practice Location Address:
1395 S COLUMBIA RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-4054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-775-3215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2005