Provider First Line Business Practice Location Address: 
2024 WASHINGTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT JOSEPH
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49085-2422
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
269-983-4500
    Provider Business Practice Location Address Fax Number: 
269-983-4500
    Provider Enumeration Date: 
07/10/2008