Provider First Line Business Practice Location Address:
11 EAST MOUNT ROYAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21202-5504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-576-2484
Provider Business Practice Location Address Fax Number:
410-576-0434
Provider Enumeration Date:
12/18/2006