Provider First Line Business Practice Location Address: 
3400 YANKEE DR
    Provider Second Line Business Practice Location Address: 
R416
    Provider Business Practice Location Address City Name: 
EAGAN
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55121-1627
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-662-2566
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/26/2013