Provider First Line Business Practice Location Address:
4826 CHICAGO AVENUE SOUTH
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-821-1920
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007