Provider First Line Business Practice Location Address:
5346 PENN AVE S
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:
55419-1065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-922-0894
Provider Business Practice Location Address Fax Number:
612-922-1352
Provider Enumeration Date:
09/13/2006