Provider First Line Business Practice Location Address:
1429 N PROSPECT 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:
53202-3017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-212-5282
Provider Business Practice Location Address Fax Number:
414-332-2368
Provider Enumeration Date:
11/12/2019