Provider First Line Business Practice Location Address:
5910 77TH ST
Provider Second Line Business Practice Location Address:
A-N-T TRANSPORTATION SUITE D
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53142-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-744-9633
Provider Business Practice Location Address Fax Number:
262-764-3442
Provider Enumeration Date:
10/27/2015