Provider First Line Business Practice Location Address:
2802 N 47TH STREET
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:
53210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-595-6592
Provider Business Practice Location Address Fax Number:
414-312-7874
Provider Enumeration Date:
09/17/2014