Provider First Line Business Practice Location Address:
819 30TH AVE 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-892-2253
Provider Business Practice Location Address Fax Number:
810-822-7254
Provider Enumeration Date:
02/02/2026