Provider First Line Business Practice Location Address:
4201 ST. ANTOINE ST
Provider Second Line Business Practice Location Address:
9C-UHC
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
332-223-0226
Provider Business Practice Location Address Fax Number:
313-966-0880
Provider Enumeration Date:
05/24/2019