Provider First Line Business Practice Location Address: 
27335 W WARREN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DEARBORN HEIGHTS
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48127-1803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-359-9999
    Provider Business Practice Location Address Fax Number: 
313-359-9998
    Provider Enumeration Date: 
12/17/2007