Provider First Line Business Practice Location Address: 
2000 E LAYTON AVE.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ST FRANCIS
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53235
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-483-3800
    Provider Business Practice Location Address Fax Number: 
414-483-3284
    Provider Enumeration Date: 
05/20/2006