Provider First Line Business Practice Location Address: 
5482 LAKERS LANE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NISSWA
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
56468-0379
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-963-3311
    Provider Business Practice Location Address Fax Number: 
218-963-3313
    Provider Enumeration Date: 
10/25/2006