Provider First Line Business Practice Location Address:
16232 PRAIRIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48221-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-268-1755
Provider Business Practice Location Address Fax Number:
313-341-2804
Provider Enumeration Date:
07/24/2023