Provider First Line Business Practice Location Address:
1929 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
NORTHBROOK MALL
Provider Business Practice Location Address City Name:
BISMARCK
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58501-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-323-8460
Provider Business Practice Location Address Fax Number:
701-323-5709
Provider Enumeration Date:
02/20/2007