Provider First Line Business Practice Location Address:
2501A N HOLTON 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:
53212-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-336-1740
Provider Business Practice Location Address Fax Number:
414-240-1392
Provider Enumeration Date:
10/23/2025