Provider First Line Business Practice Location Address: 
1101 PATRICIA LN NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAGLEY
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56621-8143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-694-4000
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/29/2008