Provider First Line Business Practice Location Address: 
110 3RD ST. S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HACKENSACK
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56452-0485
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-675-5044
    Provider Business Practice Location Address Fax Number: 
218-675-5048
    Provider Enumeration Date: 
08/22/2008