Provider First Line Business Practice Location Address: 
2529 NICOLLET AVENUE 202B
    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: 
55404
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
612-703-9194
    Provider Business Practice Location Address Fax Number: 
612-206-8881
    Provider Enumeration Date: 
03/20/2018