Provider First Line Business Practice Location Address:
1922 S CONGO AVE
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:
53204-3740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-295-3373
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2026