Provider First Line Business Practice Location Address: 
627 12TH ST E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GLENCOE
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55336-2133
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
320-864-8000
    Provider Business Practice Location Address Fax Number: 
320-864-8004
    Provider Enumeration Date: 
08/19/2011