Provider First Line Business Practice Location Address:
203 W UPHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54449-1460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-204-9697
Provider Business Practice Location Address Fax Number:
715-620-1355
Provider Enumeration Date:
12/29/2025