Provider First Line Business Practice Location Address:
2585 23RD AVE S
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-293-0006
Provider Business Practice Location Address Fax Number:
701-293-7724
Provider Enumeration Date:
03/28/2007