Provider First Line Business Practice Location Address:
2799 W GRAND BLVD
Provider Second Line Business Practice Location Address:
RM 663, MAIN CAMPUS, HENRY FORD HOSPITAL
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-428-1779
Provider Business Practice Location Address Fax Number:
313-428-1779
Provider Enumeration Date:
12/15/2025