Provider First Line Business Practice Location Address: 
18091 MUIRLAND 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: 
48221-2754
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-962-3597
    Provider Business Practice Location Address Fax Number: 
313-862-5852
    Provider Enumeration Date: 
04/05/2007