Provider First Line Business Practice Location Address: 
19190 N RIDGE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DETROIT LAKES
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56501-7650
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
320-305-1524
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/07/2015