Provider First Line Business Practice Location Address:
D128 W FEE HALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48824-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-355-3503
Provider Business Practice Location Address Fax Number:
517-432-1167
Provider Enumeration Date:
10/11/2006