Provider First Line Business Practice Location Address: 
1328 MCKAY DRIVE NE
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
HAM LAKE
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55304
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-245-3505
    Provider Business Practice Location Address Fax Number: 
651-846-6866
    Provider Enumeration Date: 
08/26/2014