Provider First Line Business Practice Location Address:
3214 N 47TH 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:
53216-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-254-9629
Provider Business Practice Location Address Fax Number:
414-447-6564
Provider Enumeration Date:
03/01/2010