Provider First Line Business Practice Location Address:
124 2ND AVE WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERTHA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-924-2124
Provider Business Practice Location Address Fax Number:
218-924-2129
Provider Enumeration Date:
08/09/2006