Provider First Line Business Practice Location Address:
2912 30TH 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:
55406-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-518-9518
Provider Business Practice Location Address Fax Number:
612-294-6553
Provider Enumeration Date:
01/22/2026