Provider First Line Business Practice Location Address:
12991 56TH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORDVILLE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58231-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-229-3215
Provider Business Practice Location Address Fax Number:
701-229-3215
Provider Enumeration Date:
05/23/2007