Provider First Line Business Practice Location Address:
1001 CENTER AVE
Provider Second Line Business Practice Location Address:
STE K
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-2080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-287-4501
Provider Business Practice Location Address Fax Number:
701-660-1052
Provider Enumeration Date:
10/31/2009