Provider First Line Business Practice Location Address:
3738 S 60TH ST
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53220-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-321-9111
Provider Business Practice Location Address Fax Number:
414-321-9112
Provider Enumeration Date:
09/19/2005