Provider First Line Business Practice Location Address: 
1012 N 3RD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MARQUETTE
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49855-3510
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
906-225-8000
    Provider Business Practice Location Address Fax Number: 
906-225-8000
    Provider Enumeration Date: 
01/15/2007