Provider First Line Business Practice Location Address: 
6517 HUNTER RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CORCORAN
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55340-9632
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
763-478-8963
    Provider Business Practice Location Address Fax Number: 
763-478-3093
    Provider Enumeration Date: 
01/13/2010