Provider First Line Business Practice Location Address:
1150 PRAIRIE PKWY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WEST FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58078-3168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-356-7766
Provider Business Practice Location Address Fax Number:
701-356-7765
Provider Enumeration Date:
06/15/2012