Provider First Line Business Practice Location Address:
1308 S 16TH 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:
53204-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-831-0100
Provider Business Practice Location Address Fax Number:
414-831-1584
Provider Enumeration Date:
12/20/2007