Provider First Line Business Practice Location Address: 
1115 S PENNSYLVANIA AVE
    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: 
48912-1669
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
517-702-3500
    Provider Business Practice Location Address Fax Number: 
517-484-5169
    Provider Enumeration Date: 
08/15/2014