Provider First Line Business Practice Location Address:
1906 30TH AVE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-2517
Provider Business Practice Location Address Fax Number:
218-233-6737
Provider Enumeration Date:
08/13/2007