Provider First Line Business Practice Location Address: 
15650 E 8 MILE RD
    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: 
48205-1444
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-526-3600
    Provider Business Practice Location Address Fax Number: 
313-526-3603
    Provider Enumeration Date: 
02/09/2006