Provider First Line Business Practice Location Address:
801 ROOSEVELT AVE
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:
56501-3703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-5401
Provider Business Practice Location Address Fax Number:
218-573-2350
Provider Enumeration Date:
06/21/2005