Provider First Line Business Practice Location Address:
6569 N CHARLES ST
Provider Second Line Business Practice Location Address:
STE 304
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-6831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-339-3904
Provider Business Practice Location Address Fax Number:
410-825-4076
Provider Enumeration Date:
09/03/2010