Provider First Line Business Practice Location Address:
1110 NORTH OLD WORLD 3RD STREET
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53203-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-271-1074
Provider Business Practice Location Address Fax Number:
414-271-1107
Provider Enumeration Date:
12/23/2008