Provider First Line Business Practice Location Address:
1ST AVE W & MARGARET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKDUCK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-835-5837
Provider Business Practice Location Address Fax Number:
218-835-4222
Provider Enumeration Date:
07/19/2006