Provider First Line Business Practice Location Address:
2501 IRVING AVE S APT 2
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:
55405-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-824-4348
Provider Business Practice Location Address Fax Number:
612-324-7422
Provider Enumeration Date:
08/22/2026