Provider First Line Business Practice Location Address: 
103 N BRIDGE ST STE 240
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHIPPEWA FALLS
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
54729-2495
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
715-379-1226
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/21/2007