Provider First Line Business Practice Location Address:
9122 PRAIRIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48204-4343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-651-9710
Provider Business Practice Location Address Fax Number:
313-651-9710
Provider Enumeration Date:
01/04/2011