Provider First Line Business Practice Location Address:
102 W CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55041-1636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-345-5241
Provider Business Practice Location Address Fax Number:
651-345-5173
Provider Enumeration Date:
12/04/2006