Provider First Line Business Practice Location Address:
6141 N 36TH 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:
53209-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-499-7542
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2026