Provider First Line Business Practice Location Address:
1132 28TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 105A
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-246-9036
Provider Business Practice Location Address Fax Number:
888-688-4095
Provider Enumeration Date:
11/24/2010