Provider First Line Business Practice Location Address:
207 E LAKE ST
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-821-0005
Provider Business Practice Location Address Fax Number:
612-821-0007
Provider Enumeration Date:
10/18/2007