Provider First Line Business Practice Location Address: 
610 N. PINE RIVER ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ITHACA
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48847
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
989-875-2888
    Provider Business Practice Location Address Fax Number: 
989-875-4604
    Provider Enumeration Date: 
06/19/2012