Provider First Line Business Practice Location Address:
501 S. 24TH AVE.
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-849-5667
Provider Business Practice Location Address Fax Number:
715-849-5677
Provider Enumeration Date:
10/03/2006