Provider First Line Business Practice Location Address:
1122 3RD 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:
56560-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-9534
Provider Business Practice Location Address Fax Number:
701-237-2625
Provider Enumeration Date:
07/23/2006