Provider First Line Business Practice Location Address:
1205 16TH AVE SOUTH
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-293-6999
Provider Business Practice Location Address Fax Number:
701-235-2297
Provider Enumeration Date:
04/02/2008