Provider First Line Business Practice Location Address:
211 S BOUNDARY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROCTOR
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55810-2306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-624-4819
Provider Business Practice Location Address Fax Number:
218-624-7323
Provider Enumeration Date:
06/28/2006