Provider First Line Business Practice Location Address: 
550 VANDALIA ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT PAUL
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55114-1833
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-855-5656
    Provider Business Practice Location Address Fax Number: 
310-876-0533
    Provider Enumeration Date: 
08/10/2009