Provider First Line Business Practice Location Address:
3700 WASHINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-945-9472
Provider Business Practice Location Address Fax Number:
262-359-6173
Provider Enumeration Date:
09/21/2026