Provider First Line Business Practice Location Address:
111 S OLD WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 212 B
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48009-6117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-738-5952
Provider Business Practice Location Address Fax Number:
248-683-8039
Provider Enumeration Date:
11/15/2006