Provider First Line Business Practice Location Address:
5411 OLD FREDERICK RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-2195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-455-6418
Provider Business Practice Location Address Fax Number:
410-455-6419
Provider Enumeration Date:
02/06/2007