Provider First Line Business Practice Location Address: 
430 10TH ST NE STE 3
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AUSTIN
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55912-3724
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
507-433-9120
    Provider Business Practice Location Address Fax Number: 
507-457-3027
    Provider Enumeration Date: 
09/03/2009