Provider First Line Business Practice Location Address: 
2824 N 55TH 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: 
53210-1559
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-763-5020
    Provider Business Practice Location Address Fax Number: 
414-755-7688
    Provider Enumeration Date: 
02/08/2018