Provider First Line Business Practice Location Address: 
3364A S NEW YORK AVE
    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: 
53207-3730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-852-9499
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/26/2014