Provider First Line Business Practice Location Address:
1126 UNIVERSITY DR N APT 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-3576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-405-5475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2026