Provider First Line Business Practice Location Address:
1615 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:
58201-5372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-795-8550
Provider Business Practice Location Address Fax Number:
701-795-8550
Provider Enumeration Date:
06/19/2007