Provider First Line Business Practice Location Address:
1210 S 61ST 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:
53214-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-252-8674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2026