Provider First Line Business Practice Location Address:
5516 CHANNING RD
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:
21229-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-267-3878
Provider Business Practice Location Address Fax Number:
240-848-7919
Provider Enumeration Date:
07/30/2025