Provider First Line Business Practice Location Address: 
18621 SNOWDEN ST
    Provider Second Line Business Practice Location Address: 
2B
    Provider Business Practice Location Address City Name: 
DETROIT
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
48235-1363
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
313-502-1635
    Provider Business Practice Location Address Fax Number: 
586-486-5772
    Provider Enumeration Date: 
09/21/2011