Provider First Line Business Practice Location Address: 
100 RIVER PLACE DR
    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: 
48207-4274
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-871-2337
    Provider Business Practice Location Address Fax Number: 
313-871-6655
    Provider Enumeration Date: 
09/24/2014