Provider First Line Business Practice Location Address: 
707 HIGHWAY 33 S
    Provider Second Line Business Practice Location Address: 
SUITE 12
    Provider Business Practice Location Address City Name: 
CLOQUET
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55720-2696
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-879-6768
    Provider Business Practice Location Address Fax Number: 
218-879-5313
    Provider Enumeration Date: 
11/28/2014