Provider First Line Business Practice Location Address:
1503 E NORTH AVE
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:
21213-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-581-2918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2026