Provider First Line Business Practice Location Address: 
2530 MARFITT RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EAST LANSING
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48823-6343
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
517-490-6975
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/29/2014