Provider First Line Business Practice Location Address:
1040 E KNAPP ST APT 314
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:
53202-2808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-498-7540
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2026