Provider First Line Business Practice Location Address:
1130 28TH AVE S
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:
56560-4419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-715-3358
Provider Business Practice Location Address Fax Number:
701-781-0316
Provider Enumeration Date:
02/18/2026