Provider First Line Business Practice Location Address:
4419 FALLS RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21211-1226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-662-7077
Provider Business Practice Location Address Fax Number:
410-889-6688
Provider Enumeration Date:
08/15/2008