Provider First Line Business Practice Location Address:
111 S OLD WOODWARD AVE
Provider Second Line Business Practice Location Address:
STE 212A
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48009-6117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-644-2900
Provider Business Practice Location Address Fax Number:
248-644-2902
Provider Enumeration Date:
07/07/2005