Provider First Line Business Practice Location Address: 
4120 W LOOMIS RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENFIELD
    Provider Business Practice Location Address State Name: 
WI
    Provider Business Practice Location Address Postal Code: 
53221-2052
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-761-4920
    Provider Business Practice Location Address Fax Number: 
414-761-4926
    Provider Enumeration Date: 
04/17/2006