Provider First Line Business Practice Location Address:
1215 N 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-322-3460
Provider Business Practice Location Address Fax Number:
507-322-3450
Provider Enumeration Date:
01/27/2008