Provider First Line Business Practice Location Address:
3422 N 49TH 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:
53216-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-943-2449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2025