Provider First Line Business Practice Location Address:
3712 LOCKPORT ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BISMARCK
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58503-5535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-223-8873
Provider Business Practice Location Address Fax Number:
701-223-1014
Provider Enumeration Date:
09/14/2006