Provider First Line Business Practice Location Address:
4627 LUMLEY ST
Provider Second Line Business Practice Location Address:
UPPER
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48210-2199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-204-2822
Provider Business Practice Location Address Fax Number:
313-822-6238
Provider Enumeration Date:
08/12/2009