Provider First Line Business Practice Location Address:
1302 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
APT 4
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21217-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-978-2130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2007