Provider First Line Business Practice Location Address:
4220 S 27TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-281-5480
Provider Business Practice Location Address Fax Number:
414-281-9866
Provider Enumeration Date:
05/28/2006