Provider First Line Business Practice Location Address:
69 N 28TH ST E
Provider Second Line Business Practice Location Address:
STE 36
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54880-6596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-392-4722
Provider Business Practice Location Address Fax Number:
715-395-2204
Provider Enumeration Date:
12/01/2005