Provider First Line Business Practice Location Address:
1231 5TH STREET NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-751-3196
Provider Business Practice Location Address Fax Number:
218-759-1171
Provider Enumeration Date:
03/04/2010