Provider First Line Business Practice Location Address: 
900 MAIN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOORHEAD
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56560-2802
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-236-0252
    Provider Business Practice Location Address Fax Number: 
218-236-8962
    Provider Enumeration Date: 
12/08/2011