Provider First Line Business Practice Location Address:
2419 S. LENOX 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:
53207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-704-1431
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2006