Provider First Line Business Practice Location Address:
2522 LAKEWOOD 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:
48215-2655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-428-1495
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2026