Provider First Line Business Practice Location Address:
1216 N PROSPECT AVE
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:
53202-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-536-8604
Provider Business Practice Location Address Fax Number:
414-536-8605
Provider Enumeration Date:
01/09/2009