Provider First Line Business Practice Location Address:
808 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 29
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-9248
Provider Business Practice Location Address Fax Number:
218-847-8874
Provider Enumeration Date:
06/24/2013