Provider First Line Business Practice Location Address:
6333 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:
53218-5515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-461-4670
Provider Business Practice Location Address Fax Number:
414-461-8393
Provider Enumeration Date:
08/20/2007