Provider First Line Business Practice Location Address: 
977 5TH ST E
    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: 
55106-5231
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
651-714-8388
    Provider Business Practice Location Address Fax Number: 
651-714-9379
    Provider Enumeration Date: 
01/12/2016