Provider First Line Business Practice Location Address: 
5331 PLYMOUTH RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ANN ARBOR
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48105-9520
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
734-996-9111
    Provider Business Practice Location Address Fax Number: 
734-996-1950
    Provider Enumeration Date: 
12/18/2007