Provider First Line Business Practice Location Address:
113 SOUTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ULLIN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58631-0670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-348-3303
Provider Business Practice Location Address Fax Number:
701-348-3913
Provider Enumeration Date:
11/15/2006