Provider First Line Business Practice Location Address:
10 1ST ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PELICAN RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-863-7511
Provider Business Practice Location Address Fax Number:
218-863-1143
Provider Enumeration Date:
10/16/2006