Provider First Line Business Practice Location Address: 
485 ARUNDEL ST
    Provider Second Line Business Practice Location Address: 
SUITE 102
    Provider Business Practice Location Address City Name: 
ST. PAUL
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55103-1931
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-797-3866
    Provider Business Practice Location Address Fax Number: 
651-207-5395
    Provider Enumeration Date: 
08/10/2009