Provider First Line Business Practice Location Address:
3238 S 16TH 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:
53215-4535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-643-4430
Provider Business Practice Location Address Fax Number:
414-643-4693
Provider Enumeration Date:
06/22/2006