Provider First Line Business Practice Location Address:
1822 SOUTH MAIN ST
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-234-3612
Provider Business Practice Location Address Fax Number:
715-234-1904
Provider Enumeration Date:
06/17/2006