Provider First Line Business Practice Location Address:
6228 PENN AVE S
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:
55423-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-866-8362
Provider Business Practice Location Address Fax Number:
612-866-1227
Provider Enumeration Date:
07/24/2006