Provider First Line Business Practice Location Address:
2500 HIGHWAY 88
Provider Second Line Business Practice Location Address:
NORTHGATE OFFICE PARK, SUITE 115
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55418-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-789-1373
Provider Business Practice Location Address Fax Number:
612-789-1373
Provider Enumeration Date:
12/25/2006