Provider First Line Business Practice Location Address:
414 W JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAHNOMEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56557-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-935-2511
Provider Business Practice Location Address Fax Number:
218-935-2370
Provider Enumeration Date:
07/09/2006