Provider First Line Business Practice Location Address:
115 WILLOW ST W
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-844-5191
Provider Business Practice Location Address Fax Number:
218-844-5193
Provider Enumeration Date:
11/21/2009