Provider First Line Business Practice Location Address:
1509 10TH AVE SOUTH
Provider Second Line Business Practice Location Address:
SUITE 16
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:
612-333-7191
Provider Business Practice Location Address Fax Number:
612-333-7194
Provider Enumeration Date:
01/18/2012