Provider First Line Business Practice Location Address:
4536 COLFAX AVE S
Provider Second Line Business Practice Location Address:
# 2
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55419-4737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-823-3679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/25/2006