Provider First Line Business Practice Location Address:
1132 28TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-422-6119
Provider Business Practice Location Address Fax Number:
218-227-5377
Provider Enumeration Date:
06/24/2014