Provider First Line Business Practice Location Address: 
384 1ST ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MANISTEE
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49660-1751
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
231-723-9911
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/14/2006