Provider First Line Business Practice Location Address: 
19940 CONANT
    Provider Second Line Business Practice Location Address: 
STE A, B, & C
    Provider Business Practice Location Address City Name: 
DETROIT
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48234-1494
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-305-4180
    Provider Business Practice Location Address Fax Number: 
313-733-8190
    Provider Enumeration Date: 
11/21/2014