Provider First Line Business Practice Location Address:
4425 N PORT WASHINGTON RD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-961-2121
Provider Business Practice Location Address Fax Number:
414-961-2102
Provider Enumeration Date:
08/19/2006