Provider First Line Business Practice Location Address:
825 SO. 8TH STR.
Provider Second Line Business Practice Location Address:
604 PARKSIDE PROFESSIONAL CENTER
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-333-3852
Provider Business Practice Location Address Fax Number:
612-333-6740
Provider Enumeration Date:
10/17/2006