Provider First Line Business Practice Location Address:
3201 PINE RIDGE AVE NW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-333-5665
Provider Business Practice Location Address Fax Number:
218-333-5642
Provider Enumeration Date:
08/17/2006