Provider First Line Business Practice Location Address:
945 N. 12TH 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:
53201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-219-7776
Provider Business Practice Location Address Fax Number:
414-219-7775
Provider Enumeration Date:
09/01/2016