Provider First Line Business Practice Location Address:
5900 S. LAKE DRIVE
Provider Second Line Business Practice Location Address:
LAKESHORE MEDICAL CLINIC
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53110-3171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-489-4190
Provider Business Practice Location Address Fax Number:
414-489-4015
Provider Enumeration Date:
11/01/2006