Provider First Line Business Practice Location Address:
910 11TH ST 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:
56560-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-284-6316
Provider Business Practice Location Address Fax Number:
218-284-6333
Provider Enumeration Date:
01/28/2026