Provider First Line Business Practice Location Address:
3046 S 13TH 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:
53215-3826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-649-9696
Provider Business Practice Location Address Fax Number:
414-649-9698
Provider Enumeration Date:
11/19/2007