Provider First Line Business Practice Location Address:
2902 N 1ST 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:
53212-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-372-0739
Provider Business Practice Location Address Fax Number:
414-372-0739
Provider Enumeration Date:
12/29/2006