Provider First Line Business Practice Location Address:
4115 N 36TH 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:
53210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-871-1515
Provider Business Practice Location Address Fax Number:
414-871-1503
Provider Enumeration Date:
11/27/2007