Provider First Line Business Practice Location Address:
4791 COUNTY ROAD 10 STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOOSE LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55767-9221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-485-2020
Provider Business Practice Location Address Fax Number:
218-485-2044
Provider Enumeration Date:
11/22/2011