Provider First Line Business Practice Location Address:
2300 4TH AVE S
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:
56560-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-284-2412
Provider Business Practice Location Address Fax Number:
218-284-2347
Provider Enumeration Date:
09/16/2006