Provider First Line Business Practice Location Address:
1220 MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-8201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-5433
Provider Business Practice Location Address Fax Number:
701-364-2256
Provider Enumeration Date:
08/31/2010