Provider First Line Business Practice Location Address:
516 15TH AVE S E
Provider Second Line Business Practice Location Address:
INTERCOLLEGIATE ATHLETICS ROOM 250 BFAB
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-625-5084
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2006