Provider First Line Business Practice Location Address:
2136 20 1/8TH ST.
Provider Second Line Business Practice Location Address:
#22
Provider Business Practice Location Address City Name:
RICE LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54868-0494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-719-0332
Provider Business Practice Location Address Fax Number:
715-719-0332
Provider Enumeration Date:
08/10/2009