Provider First Line Business Practice Location Address:
4641 PARK HEIGHTS 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:
21215-6331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-571-9174
Provider Business Practice Location Address Fax Number:
410-364-8284
Provider Enumeration Date:
09/17/2025