Provider First Line Business Practice Location Address:
4683 N 74TH 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:
53218-4750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-810-0057
Provider Business Practice Location Address Fax Number:
414-810-0006
Provider Enumeration Date:
01/28/2026