Provider First Line Business Practice Location Address:
100 POLK COUNTY PLZ
Provider Second Line Business Practice Location Address:
SUITE 50
Provider Business Practice Location Address City Name:
BALSAM LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54810-9071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-485-8424
Provider Business Practice Location Address Fax Number:
715-485-8490
Provider Enumeration Date:
04/12/2007