Provider First Line Business Practice Location Address: 
1732 W BETHUNE ST
    Provider Second Line Business Practice Location Address: 
APT 4
    Provider Business Practice Location Address City Name: 
DETROIT
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48206-2721
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-404-3134
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/04/2016