Provider First Line Business Practice Location Address:
115 EAST LAKE ST
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:
55408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-827-3857
Provider Business Practice Location Address Fax Number:
612-827-7204
Provider Enumeration Date:
09/25/2006