Provider First Line Business Practice Location Address:
209 1ST ST SW
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-935-2211
Provider Business Practice Location Address Fax Number:
218-935-5921
Provider Enumeration Date:
10/19/2006