Provider First Line Business Practice Location Address: 
2253 16TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MONROE
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53566-2604
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
608-558-5912
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/19/2011