Provider First Line Business Practice Location Address:
1584 N PROSPECT AVE
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:
53202-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-276-5760
Provider Business Practice Location Address Fax Number:
414-276-6076
Provider Enumeration Date:
02/12/2007