Provider First Line Business Practice Location Address:
117 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-345-3039
Provider Business Practice Location Address Fax Number:
651-345-3506
Provider Enumeration Date:
07/02/2006