Provider First Line Business Practice Location Address:
221 HIGHWAY 53
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
COOK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55723-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-666-2697
Provider Business Practice Location Address Fax Number:
218-666-2620
Provider Enumeration Date:
01/05/2010