Provider First Line Business Practice Location Address:
1200 6TH AVENUE NORTH
Provider Second Line Business Practice Location Address:
CENTRACARE CLINIC RIVER CAMPUS
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-240-2207
Provider Business Practice Location Address Fax Number:
320-240-7896
Provider Enumeration Date:
11/15/2007