Provider First Line Business Practice Location Address:
4350 S WASHINGTON ST; STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-780-6204
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2011