Provider First Line Business Practice Location Address: 
565 W. MICHIGAN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SALINE
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48176-9522
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
734-944-4333
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/04/2006