Provider First Line Business Practice Location Address: 
13530 MICHIGAN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DEARBORN
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48126-3574
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
734-673-5917
    Provider Business Practice Location Address Fax Number: 
314-667-6915
    Provider Enumeration Date: 
12/30/2014