Provider First Line Business Practice Location Address: 
114 S BROWNSON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KINGSLEY
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49649-5103
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
231-263-7701
    Provider Business Practice Location Address Fax Number: 
231-263-7925
    Provider Enumeration Date: 
07/20/2006