Provider First Line Business Practice Location Address: 
48709 VAN DYKE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UTICA
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48317
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
586-731-3000
    Provider Business Practice Location Address Fax Number: 
586-731-7522
    Provider Enumeration Date: 
10/05/2006