Provider First Line Business Practice Location Address: 
3905 SILVER LAKE RD NE
    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: 
55421-4352
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
763-559-0859
    Provider Business Practice Location Address Fax Number: 
763-559-4356
    Provider Enumeration Date: 
07/24/2014