Provider First Line Business Practice Location Address:
4111 N PORT WASHINGTON RD
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:
53212-1029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-299-3872
Provider Business Practice Location Address Fax Number:
414-455-1929
Provider Enumeration Date:
02/11/2016