Provider First Line Business Practice Location Address:
415 SE 13TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-4248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-326-5424
Provider Business Practice Location Address Fax Number:
218-327-4930
Provider Enumeration Date:
07/21/2005