Provider First Line Business Practice Location Address:
11455 VIKING DR
Provider Second Line Business Practice Location Address:
STE 300, PARK NICOLLET CLINIC - ALEXANDER CENTER
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-7251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-2498
Provider Business Practice Location Address Fax Number:
952-993-2557
Provider Enumeration Date:
12/27/2005