Provider First Line Business Practice Location Address:
10302 COUNTY ROAD 147
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-7057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-841-8682
Provider Business Practice Location Address Fax Number:
218-844-6500
Provider Enumeration Date:
06/11/2010