Provider First Line Business Practice Location Address: 
4625 CHURCHILL STREET
    Provider Second Line Business Practice Location Address: 
MOTIONCARE SHOREVIEW MEDICAL CENTER SUITE 204
    Provider Business Practice Location Address City Name: 
SHOREVIEW
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55126
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-484-6735
    Provider Business Practice Location Address Fax Number: 
651-484-5663
    Provider Enumeration Date: 
08/18/2006