Provider First Line Business Practice Location Address: 
817 MAIN ST NE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MINNEAPOLIS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55413-1931
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-362-2418
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/06/2011