Provider First Line Business Practice Location Address:
1134 W NORTH AVE FL 2
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:
53205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-269-9660
Provider Business Practice Location Address Fax Number:
414-435-3126
Provider Enumeration Date:
02/27/2007