Provider First Line Business Practice Location Address:
1136 WASHINGTON AVE
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:
56501-3411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-2624
Provider Business Practice Location Address Fax Number:
218-847-5792
Provider Enumeration Date:
07/21/2006