Provider First Line Business Practice Location Address:
212 8TH ST S
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-2875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-7744
Provider Business Practice Location Address Fax Number:
218-236-7733
Provider Enumeration Date:
12/12/2006