| Entity Type | Organization |
| |
| Provider Organization | MI SKIN CENTER, PLLC |
| Practice Office Address | 133 WEST MAIN STREET
SUITE 251
NORTHVILLE, MI US |
| Practice Office Telephone | 2489635915 |
| Practice Office Fax | 2482784854 |
| Mailing Address | 18561 STEEP HOLLOW CT
NORTHVILLE, MI 48168 US |
| Business Telephone | 3106226188 |
| Business Fax | 2482784854 |
| Authorized Official | FRANCISCA M.S. KARTONO WINARDI, PRESIDENT
3106226188 |