Provider First Line Business Practice Location Address: 
225 EAST FIRST STREET NORTH
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MELROSE
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56352
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
320-256-4317
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/20/2007