Provider First Line Business Practice Location Address:
9200 W WISCONSIN AVE DEPT OF
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:
53226-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-955-7113
Provider Business Practice Location Address Fax Number:
414-805-8097
Provider Enumeration Date:
06/01/2009