Provider First Line Business Practice Location Address:
1602 30TH AVE. S.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-4402
Provider Business Practice Location Address Fax Number:
218-233-1026
Provider Enumeration Date:
09/20/2006