Provider First Line Business Practice Location Address:
8106 W CONGRESS 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:
53218-4532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-366-9258
Provider Business Practice Location Address Fax Number:
414-368-0111
Provider Enumeration Date:
11/01/2022