Provider First Line Business Practice Location Address:
1006 INGLESIDE 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:
21228-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-747-1707
Provider Business Practice Location Address Fax Number:
410-747-2608
Provider Enumeration Date:
09/20/2006