Provider First Line Business Practice Location Address: 
820 SHERBROOK STREET
    Provider Second Line Business Practice Location Address: 
GC404, HEALTH SCIENCES CENTER
    Provider Business Practice Location Address City Name: 
MANITOBA
    Provider Business Practice Location Address State Name: 
WINNIPEG
    Provider Business Practice Location Address Postal Code: 
R3A1R9
    Provider Business Practice Location Address Country Code: 
CA
    Provider Business Practice Location Address Telephone Number: 
204-787-1485
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/03/2016