Provider First Line Business Practice Location Address: 
2455 S. HOWELL 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
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-744-7001
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/14/2008