Provider First Line Business Mailing Address:
400 MACK BLVD, SUITE 2 WEST
Provider Second Line Business Mailing Address:
CREDENTIALING DEPT.
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-448-9006
Provider Business Mailing Address Fax Number: