Provider First Line Business Practice Location Address:
18 2ND ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56347-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-874-0768
Provider Business Practice Location Address Fax Number:
320-732-8161
Provider Enumeration Date:
11/02/2005