Provider First Line Business Practice Location Address: 
6508 W LINCOLN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WEST ALLIS
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53219-2045
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-810-0009
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/13/2006