Provider First Line Business Practice Location Address: 
14 N 11TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLOQUET
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55720-1607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-879-4583
    Provider Business Practice Location Address Fax Number: 
218-879-2500
    Provider Enumeration Date: 
07/28/2011