Provider First Line Business Practice Location Address:
2312 42ND ST 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:
56560-8218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-543-6313
Provider Business Practice Location Address Fax Number:
701-935-7176
Provider Enumeration Date:
02/12/2026