Provider First Line Business Practice Location Address:
1507 W KNAPP 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:
54868-1383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-823-0508
Provider Business Practice Location Address Fax Number:
866-245-8064
Provider Enumeration Date:
08/05/2006