Provider First Line Business Practice Location Address:
420 CENTER AVENUE
Provider Second Line Business Practice Location Address:
SUITE 48
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-5151
Provider Business Practice Location Address Fax Number:
218-236-5866
Provider Enumeration Date:
12/13/2006