Provider First Line Business Practice Location Address: 
1100 N MAIN ST
    Provider Second Line Business Practice Location Address: 
SUITE 117
    Provider Business Practice Location Address City Name: 
ANN ARBOR
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48104-1059
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
734-214-3890
    Provider Business Practice Location Address Fax Number: 
734-214-0644
    Provider Enumeration Date: 
02/28/2008