Provider First Line Business Practice Location Address: 
N3039 QUINNESEC LAKE ANTOINE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
IRON MOUNTAIN
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49801-9638
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
906-779-5893
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/30/2011