Provider First Line Business Practice Location Address:
1575 WEST BIG BEAVER SU
Provider Second Line Business Practice Location Address:
MEDICAL SQUARE OF TROY
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-649-1410
Provider Business Practice Location Address Fax Number:
248-649-7205
Provider Enumeration Date:
09/16/2006