Provider First Line Business Practice Location Address:
2303 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-6316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-775-8462
Provider Business Practice Location Address Fax Number:
701-775-0452
Provider Enumeration Date:
04/16/2007