Provider First Line Business Practice Location Address:
10303 N PORT WASHINGTON RD STE 203
Provider Second Line Business Practice Location Address:
NORTH SHORE CENTER LLC
Provider Business Practice Location Address City Name:
MEQUON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53092-5760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-241-5955
Provider Business Practice Location Address Fax Number:
262-241-5926
Provider Enumeration Date:
11/16/2006