Provider First Line Business Practice Location Address:
403 1ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELL LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54871-0300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-468-2552
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006