Provider First Line Business Practice Location Address:
2173 S KINNICKINNIC AVE
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:
53207-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-739-8959
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2026