Provider First Line Business Practice Location Address:
16583 PRAIRIE ST
Provider Second Line Business Practice Location Address:
SUITE NUMBER 1
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48221-2914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-506-4882
Provider Business Practice Location Address Fax Number:
313-341-1497
Provider Enumeration Date:
12/07/2011