Provider First Line Business Practice Location Address:
1823 N HUMBOLDT 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:
53202-1624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-273-8415
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2006