Provider First Line Business Practice Location Address:
1383 21ST AVE N SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-235-8050
Provider Business Practice Location Address Fax Number:
701-298-3738
Provider Enumeration Date:
01/31/2007