Provider First Line Business Practice Location Address:
1500 30TH AVE S STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-5146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-451-3614
Provider Business Practice Location Address Fax Number:
218-512-0685
Provider Enumeration Date:
09/28/2007