Provider First Line Business Practice Location Address:
1507 W KNAPP ST UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICE LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54868-1384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-855-0408
Provider Business Practice Location Address Fax Number:
715-855-0409
Provider Enumeration Date:
04/24/2007