Provider First Line Business Practice Location Address: 
90 E LAKE COWDRY RD NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALEXANDRIA
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56308-8254
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
320-762-8345
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/25/2014