Provider First Line Business Practice Location Address: 
1706 UNIVERSITY AVE W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT PAUL
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55104-3614
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-645-3661
    Provider Business Practice Location Address Fax Number: 
651-645-0959
    Provider Enumeration Date: 
07/29/2014