Provider First Line Business Practice Location Address: 
617 CEDAR AVE S
    Provider Second Line Business Practice Location Address: 
A
    Provider Business Practice Location Address City Name: 
MINNEAPOLIS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55454-1220
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-867-9699
    Provider Business Practice Location Address Fax Number: 
612-354-7152
    Provider Enumeration Date: 
07/18/2012