Provider First Line Business Practice Location Address:
45 21ST AVENUE EAST
Provider Second Line Business Practice Location Address:
UNIT D
Provider Business Practice Location Address City Name:
WEST FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58078-7811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-893-3150
Provider Business Practice Location Address Fax Number:
701-893-3155
Provider Enumeration Date:
10/31/2007