Provider First Line Business Practice Location Address: 
1913 SOUTH BLVD W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TROY
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48098-1786
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
248-828-3185
    Provider Business Practice Location Address Fax Number: 
248-828-0197
    Provider Enumeration Date: 
01/04/2006