Provider First Line Business Practice Location Address: 
909 LOGAN AVE N
    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: 
55411-3814
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-702-8415
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/12/2007