Provider First Line Business Practice Location Address:
16425 UPPER 22ND ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55043-9718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-544-4824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/11/2025