Provider First Line Business Practice Location Address:
156 N LAKEWOOD 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:
21224-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-417-8334
Provider Business Practice Location Address Fax Number:
804-999-0621
Provider Enumeration Date:
03/27/2015