Provider First Line Business Practice Location Address:
215 N 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PROCTOR
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55810-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-4265
Provider Business Practice Location Address Fax Number:
218-722-4265
Provider Enumeration Date:
03/20/2007