Provider First Line Business Practice Location Address:
2101 ELM ST N
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:
58102-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-639-2879
Provider Business Practice Location Address Fax Number:
701-540-0409
Provider Enumeration Date:
07/20/2006