Provider First Line Business Practice Location Address:
325 N 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401-4484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-268-9762
Provider Business Practice Location Address Fax Number:
866-579-8575
Provider Enumeration Date:
12/28/2010