Provider First Line Business Practice Location Address:
2821 N. 4TH STREET
Provider Second Line Business Practice Location Address:
SUITE 139
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-264-4217
Provider Business Practice Location Address Fax Number:
414-264-4218
Provider Enumeration Date:
11/01/2006