Provider First Line Business Practice Location Address:
4570 CTY HWY 61
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOOSE LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55767-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-485-4491
Provider Business Practice Location Address Fax Number:
218-485-4724
Provider Enumeration Date:
05/23/2005