Provider First Line Business Practice Location Address:
1020 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53233-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-647-6936
Provider Business Practice Location Address Fax Number:
414-385-1599
Provider Enumeration Date:
10/14/2005