Provider First Line Business Practice Location Address: 
13 MAIN AVE N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAGLEY
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56621-0299
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-964-6571
    Provider Business Practice Location Address Fax Number: 
218-694-6555
    Provider Enumeration Date: 
12/20/2007