Provider First Line Business Practice Location Address: 
515 MOOS HEALTH SCIENCE TOWER
    Provider Second Line Business Practice Location Address: 
9-176
    Provider Business Practice Location Address City Name: 
MINNEAPOLIS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55455
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-625-5655
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2009