Provider First Line Business Practice Location Address:
410 S 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HALLOCK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56728-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-843-2113
Provider Business Practice Location Address Fax Number:
218-843-2020
Provider Enumeration Date:
03/08/2007