Provider First Line Business Practice Location Address:
19229 COUNTY 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56470-6487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-732-0456
Provider Business Practice Location Address Fax Number:
218-732-6999
Provider Enumeration Date:
01/15/2008