Provider First Line Business Practice Location Address:
1900 28TH 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:
56560-4830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-299-6819
Provider Business Practice Location Address Fax Number:
218-299-6532
Provider Enumeration Date:
12/12/2006