Provider First Line Business Practice Location Address: 
503 4TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUGHTON
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49931-2309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
906-284-2350
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/28/2011