Provider First Line Business Practice Location Address:
219 GRANT UTLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASS LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56633-0067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-335-2559
Provider Business Practice Location Address Fax Number:
218-335-2755
Provider Enumeration Date:
06/28/2006