Provider First Line Business Practice Location Address: 
6018 HARFORD 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: 
21214-1327
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
443-559-1875
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/29/2023