Provider First Line Business Practice Location Address:
1416 CENTRAL AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST GRAND FORKS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56721-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-773-3004
Provider Business Practice Location Address Fax Number:
218-773-3006
Provider Enumeration Date:
07/17/2013