Provider First Line Business Practice Location Address: 
1121 CROOKS RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROYAL OAK
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48067-1301
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
248-541-8554
    Provider Business Practice Location Address Fax Number: 
248-541-1791
    Provider Enumeration Date: 
11/23/2005