Provider First Line Business Practice Location Address:
1180 BROOKDALE MALL, SP. #30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-566-8166
Provider Business Practice Location Address Fax Number:
763-566-5627
Provider Enumeration Date:
12/21/2006