Provider First Line Business Practice Location Address:
2817 NEW PINERY RD.
Provider Second Line Business Practice Location Address:
DIVINE SAVIOR HEATHCARE, INC.
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53901-0387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-745-5176
Provider Business Practice Location Address Fax Number:
608-745-0451
Provider Enumeration Date:
07/28/2005