Provider First Line Business Practice Location Address:
1010 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54302-1481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-445-7095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2025