Provider First Line Business Practice Location Address:
2624 9TH AVE SW
Provider Second Line Business Practice Location Address:
SOUTHEAST HUMAN SERVICE CENTER
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-298-4445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2006