Provider First Line Business Practice Location Address:
2121 S KINNICKINNIC AVE
Provider Second Line Business Practice Location Address:
SUITE THREE
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53207-1364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-744-0707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2007