Provider First Line Business Practice Location Address: 
80 HAMPSHIRE AVE N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GOLDEN VALLEY
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55427-4923
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-889-4291
    Provider Business Practice Location Address Fax Number: 
763-546-8189
    Provider Enumeration Date: 
12/04/2006