Provider First Line Business Practice Location Address:
2036 E PRATT ST
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:
21231-1934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-320-0610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2010