Provider First Line Business Practice Location Address: 
1000 ST HWY 13
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WISCONSIN DELLS
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53965-0049
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
608-254-4244
    Provider Business Practice Location Address Fax Number: 
608-253-5714
    Provider Enumeration Date: 
06/04/2007