Provider First Line Business Practice Location Address:
101 11TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-2899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-7365
Provider Business Practice Location Address Fax Number:
218-233-5702
Provider Enumeration Date:
02/24/2007