Provider First Line Business Practice Location Address: 
5650 BAY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAGINAW
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48604-2510
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
989-790-7431
    Provider Business Practice Location Address Fax Number: 
989-790-7520
    Provider Enumeration Date: 
01/12/2016