Provider First Line Business Practice Location Address:
3100 WASHIHGTON ROAD
Provider Second Line Business Practice Location Address:
WASHINGTON MANOR
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-658-4039
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2008