Provider First Line Business Practice Location Address:
205 W BRIDGE ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-842-3704
Provider Business Practice Location Address Fax Number:
715-842-4207
Provider Enumeration Date:
05/24/2005