Provider First Line Business Practice Location Address:
1020 N 12TH 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:
53233-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-219-7963
Provider Business Practice Location Address Fax Number:
414-219-7964
Provider Enumeration Date:
03/21/2013