Provider First Line Business Practice Location Address:
1840 N PROSPECT 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:
53202-1975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-831-6877
Provider Business Practice Location Address Fax Number:
414-831-6765
Provider Enumeration Date:
10/30/2009