Provider First Line Business Practice Location Address:
301 COUNTY ROAD 12B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RIVER
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58270-4134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-284-7115
Provider Business Practice Location Address Fax Number:
701-284-7117
Provider Enumeration Date:
11/07/2005