Provider First Line Business Practice Location Address:
402 JAMES STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-2965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-829-4243
Provider Business Practice Location Address Fax Number:
218-825-8102
Provider Enumeration Date:
12/19/2006