Provider First Line Business Practice Location Address:
2468 SOUTH KINNICKINNIC AVENUE
Provider Second Line Business Practice Location Address:
UNIT 301
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-943-1739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2026