Provider First Line Business Practice Location Address:
2211 10TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SOUTH MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53172-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-766-9390
Provider Business Practice Location Address Fax Number:
414-766-9392
Provider Enumeration Date:
08/29/2012