Provider First Line Business Practice Location Address: 
3915 W SAGINAW HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LANSING
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48917-2105
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
517-703-0593
    Provider Business Practice Location Address Fax Number: 
517-703-0597
    Provider Enumeration Date: 
09/25/2011