Provider First Line Business Practice Location Address:
130 LABREE AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-589-4902
Provider Business Practice Location Address Fax Number:
320-589-2543
Provider Enumeration Date:
10/17/2006