Provider First Line Business Practice Location Address:
3901 CHICAGO AVENUE SOUTH
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:
55407-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-824-0415
Provider Business Practice Location Address Fax Number:
612-825-0789
Provider Enumeration Date:
06/21/2005