Provider First Line Business Practice Location Address: 
97 85TH AVE NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COON RAPIDS
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55433-6022
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
952-224-9785
    Provider Business Practice Location Address Fax Number: 
952-224-9790
    Provider Enumeration Date: 
11/30/2006