Provider First Line Business Practice Location Address:
1809 NORTHWESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54403-9312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-234-7187
Provider Business Practice Location Address Fax Number:
715-257-4414
Provider Enumeration Date:
09/05/2025