Provider First Line Business Practice Location Address:
2717 E 42ND ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-247-2338
Provider Business Practice Location Address Fax Number:
612-728-2039
Provider Enumeration Date:
11/30/2006