Provider First Line Business Practice Location Address:
112 1ST ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-4002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-888-8032
Provider Business Practice Location Address Fax Number:
218-308-6438
Provider Enumeration Date:
12/28/2017