Provider First Line Business Practice Location Address:
1100 32ND AVE S
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-5012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-477-7774
Provider Business Practice Location Address Fax Number:
218-477-7774
Provider Enumeration Date:
02/27/2007