Provider First Line Business Practice Location Address: 
4261 PENN AVE N
    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: 
55412-1537
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
763-843-0593
    Provider Business Practice Location Address Fax Number: 
612-607-7702
    Provider Enumeration Date: 
06/17/2020