Provider First Line Business Practice Location Address:
148 PARKDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANISTEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49660-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-723-1190
Provider Business Practice Location Address Fax Number:
231-723-1467
Provider Enumeration Date:
06/22/2005