Provider First Line Business Practice Location Address:
317 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-1762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-371-7753
Provider Business Practice Location Address Fax Number:
701-232-5534
Provider Enumeration Date:
03/18/2009