Provider First Line Business Practice Location Address:
200 STATE HIGHWAY 55 EAST
Provider Second Line Business Practice Location Address:
BOX 820
Provider Business Practice Location Address City Name:
MAPLE LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55358-0820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-963-3171
Provider Business Practice Location Address Fax Number:
320-963-3170
Provider Enumeration Date:
12/01/2006