Provider First Line Business Practice Location Address: 
2300 HAGGERTY RD
    Provider Second Line Business Practice Location Address: 
SUITE 2040
    Provider Business Practice Location Address City Name: 
WEST BLOOMFIELD
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48323-2184
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
248-624-0008
    Provider Business Practice Location Address Fax Number: 
248-624-8483
    Provider Enumeration Date: 
02/13/2007