Provider First Line Business Practice Location Address:
12800 KELLY RD
Provider Second Line Business Practice Location Address:
ST JOHN HEALTH CENTER, RM 102B
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48224-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-372-3826
Provider Business Practice Location Address Fax Number:
313-372-3990
Provider Enumeration Date:
09/04/2012