Provider First Line Business Practice Location Address:
211 5TH ST S
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-1754
Provider Business Practice Location Address Fax Number:
218-291-1640
Provider Enumeration Date:
10/10/2006