Provider First Line Business Practice Location Address: 
112 S STATE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT IGNACE
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49781-1618
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
906-643-7725
    Provider Business Practice Location Address Fax Number: 
906-643-6345
    Provider Enumeration Date: 
10/20/2006