Provider First Line Business Practice Location Address:
36510 COUNTY RD 21
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE EARTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-983-3285
Provider Business Practice Location Address Fax Number:
218-983-3742
Provider Enumeration Date:
08/04/2006