Provider First Line Business Practice Location Address:
1220 MAIN AVE STE 105
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:
58103-8201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-660-3006
Provider Business Practice Location Address Fax Number:
701-660-3391
Provider Enumeration Date:
07/17/2026