Provider First Line Business Practice Location Address: 
555 W BROADWAY AVE
    Provider Second Line Business Practice Location Address: 
SUITES 2 AND 3
    Provider Business Practice Location Address City Name: 
FOREST LAKE
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55025-1175
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-251-5226
    Provider Business Practice Location Address Fax Number: 
651-251-5279
    Provider Enumeration Date: 
02/16/2016