Provider First Line Business Practice Location Address:
1401 8TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-451-4811
Provider Business Practice Location Address Fax Number:
218-451-4840
Provider Enumeration Date:
02/21/2007