Provider First Line Business Practice Location Address: 
20460 CO. RD.11 NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIG LAKE
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
763-263-7100
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/23/2007