Provider First Line Business Practice Location Address: 
600 WEST 98TH STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BLOOMINGTON
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55420-4773
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
952-881-2651
    Provider Business Practice Location Address Fax Number: 
952-885-6065
    Provider Enumeration Date: 
04/29/2006