Provider First Line Business Practice Location Address:
123 19TH STREET NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-886-0123
Provider Business Practice Location Address Fax Number:
605-886-5447
Provider Enumeration Date:
09/20/2006