Provider First Line Business Practice Location Address:
2311 N PROSPECT AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-4445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-319-3098
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006