Provider First Line Business Practice Location Address:
1829 E 30TH 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:
21218-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-768-1736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2026