Provider First Line Business Practice Location Address:
62 UPPER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PORTAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55605-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-475-2235
Provider Business Practice Location Address Fax Number:
218-475-2261
Provider Enumeration Date:
10/27/2006