Provider First Line Business Practice Location Address:
4730 CHICAGO AVENUE SOUTH
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:
55407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-824-4211
Provider Business Practice Location Address Fax Number:
612-824-2904
Provider Enumeration Date:
08/16/2006