Provider First Line Business Practice Location Address:
900 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
SUITE B102
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-2643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-937-5569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2010