Provider First Line Business Practice Location Address: 
575 COURT ST
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
WEST BRANCH
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48661-9387
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
989-345-1126
    Provider Business Practice Location Address Fax Number: 
989-345-4752
    Provider Enumeration Date: 
02/08/2007