Provider First Line Business Practice Location Address:
1209 SE 2ND AVE
Provider Second Line Business Practice Location Address:
ITASCA RESOURCE CENTER
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-3982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-327-5525
Provider Business Practice Location Address Fax Number:
218-327-5546
Provider Enumeration Date:
12/18/2008