Provider First Line Business Practice Location Address:
1720 HIGHWAY 59 SOUTHEAST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701-0505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-681-3300
Provider Business Practice Location Address Fax Number:
218-681-6733
Provider Enumeration Date:
11/16/2006