Provider First Line Business Practice Location Address:
1230 GRANT 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:
53213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-286-8892
Provider Business Practice Location Address Fax Number:
414-384-5578
Provider Enumeration Date:
08/05/2006