Provider First Line Business Practice Location Address:
219 FRONT ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-5649
Provider Business Practice Location Address Fax Number:
218-847-8110
Provider Enumeration Date:
11/20/2006