Provider First Line Business Practice Location Address: 
2925 CHICAGO AVE
    Provider Second Line Business Practice Location Address: 
10307
    Provider Business Practice Location Address City Name: 
MINNEAPOLIS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55407-1321
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-262-5247
    Provider Business Practice Location Address Fax Number: 
612-262-4091
    Provider Enumeration Date: 
04/24/2007