Provider First Line Business Practice Location Address:
1319 LIGHT 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:
21230-4307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-789-1084
Provider Business Practice Location Address Fax Number:
410-636-2563
Provider Enumeration Date:
09/06/2006