Provider First Line Business Practice Location Address: 
4001 STINSON BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 420
    Provider Business Practice Location Address City Name: 
MINNEAPOLIS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55421-3488
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-788-5151
    Provider Business Practice Location Address Fax Number: 
612-788-9698
    Provider Enumeration Date: 
07/24/2006