Provider First Line Business Practice Location Address:
6423 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:
53223-6004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-218-4980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2026