Provider First Line Business Practice Location Address: 
416 REDBRIDGE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIDDLE RIVER
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21220-2008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
443-474-8210
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/03/2023