Provider First Line Business Practice Location Address:
401 5TH ST
Provider Second Line Business Practice Location Address:
STE 235
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54403-5470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-849-3311
Provider Business Practice Location Address Fax Number:
715-849-8414
Provider Enumeration Date:
12/14/2006