Provider First Line Business Practice Location Address:
393 N DUNLAP ST
Provider Second Line Business Practice Location Address:
SUITE 100 CENTRAL MEDICAL BLDG
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-646-1318
Provider Business Practice Location Address Fax Number:
651-642-2592
Provider Enumeration Date:
11/21/2006