Provider First Line Business Practice Location Address: 
1164 JAMES SAVAGE RD
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
MIDLAND
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48640-6843
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
248-767-7568
    Provider Business Practice Location Address Fax Number: 
734-418-1057
    Provider Enumeration Date: 
03/30/2011