Provider First Line Business Practice Location Address:
1700 30TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-5608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-444-4346
Provider Business Practice Location Address Fax Number:
218-444-4083
Provider Enumeration Date:
12/26/2012