Provider First Line Business Practice Location Address:
1002 1ST AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-630-9536
Provider Business Practice Location Address Fax Number:
888-959-2798
Provider Enumeration Date:
07/19/2005