Provider First Line Business Practice Location Address:
702 5TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-2976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-751-9533
Provider Business Practice Location Address Fax Number:
218-444-4759
Provider Enumeration Date:
06/28/2005