| NPI | 1225309248 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NICHOLAS RYAN JOHNSON President/Owner 320-864-6249 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: MN 5603) |
| Enumeration Date | 2012-01-23 |
| Last Update Date | 2012-01-23 |