Provider First Line Business Practice Location Address: 
1810 MCKINNEY AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BENSON
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56215-1638
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
320-843-2030
    Provider Business Practice Location Address Fax Number: 
320-843-4172
    Provider Enumeration Date: 
05/21/2018