Provider First Line Business Practice Location Address:
3624 E LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55406-2152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-729-2361
Provider Business Practice Location Address Fax Number:
612-729-2362
Provider Enumeration Date:
03/30/2006