Provider First Line Business Practice Location Address: 
14750 CEDAR AVE
    Provider Second Line Business Practice Location Address: 
SUITE 101
    Provider Business Practice Location Address City Name: 
APPLE VALLEY
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55124-4506
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
952-891-1191
    Provider Business Practice Location Address Fax Number: 
952-891-1192
    Provider Enumeration Date: 
04/21/2009