Provider First Line Business Practice Location Address:
6318 WIRT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215-3125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-514-6232
Provider Business Practice Location Address Fax Number:
845-350-5381
Provider Enumeration Date:
01/24/2010