Provider First Line Business Practice Location Address: 
423 NE 4TH ST STE 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GRAND RAPIDS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55744-2968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-326-5694
    Provider Business Practice Location Address Fax Number: 
218-326-5313
    Provider Enumeration Date: 
12/26/2005