Provider First Line Business Practice Location Address:
2708 IRVING 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:
55411-1227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-522-7792
Provider Business Practice Location Address Fax Number:
612-588-9945
Provider Enumeration Date:
01/26/2008