Provider First Line Business Practice Location Address: 
324 W SUPERIOR ST
    Provider Second Line Business Practice Location Address: 
STE 600
    Provider Business Practice Location Address City Name: 
DULUTH
    Provider Business Practice Location Address State Name: 
MN
    Provider Business Practice Location Address Postal Code: 
55802-1701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
218-723-8153
    Provider Business Practice Location Address Fax Number: 
218-722-7625
    Provider Enumeration Date: 
12/21/2006