Provider First Line Business Practice Location Address:
3210 18TH ST SO
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:
58104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-237-6008
Provider Business Practice Location Address Fax Number:
701-893-3017
Provider Enumeration Date:
05/22/2007