Provider First Line Business Practice Location Address:
1293 E. PARKDALE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1200A
Provider Business Practice Location Address City Name:
MANISTEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-398-1550
Provider Business Practice Location Address Fax Number:
231-398-1691
Provider Enumeration Date:
10/28/2005