Provider First Line Business Practice Location Address:
3046 S 47TH 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:
53219-3434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-940-0775
Provider Business Practice Location Address Fax Number:
414-921-1820
Provider Enumeration Date:
04/24/2009