Provider First Line Business Practice Location Address:
1612 S 55TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53214-5244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-349-0619
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2026