Provider First Line Business Practice Location Address:
1700 TAINTER ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MENOMONIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54751-8200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-235-4291
Provider Business Practice Location Address Fax Number:
715-235-4292
Provider Enumeration Date:
04/23/2008