Provider First Line Business Practice Location Address:
1104 4TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56347-0008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-732-3516
Provider Business Practice Location Address Fax Number:
320-732-7018
Provider Enumeration Date:
05/17/2007