Provider First Line Business Practice Location Address:
2471 310TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAHNOMEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-935-2238
Provider Business Practice Location Address Fax Number:
218-935-5085
Provider Enumeration Date:
08/11/2006