Provider First Line Business Practice Location Address: 
701 W PRATT ST
    Provider Second Line Business Practice Location Address: 
RM 474
    Provider Business Practice Location Address City Name: 
BALTIMORE
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21201-1023
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-328-6325
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/20/2013