Provider First Line Business Practice Location Address:
1146 HOUSEMAN AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-1230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-740-2171
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2025