Provider First Line Business Practice Location Address:
5705 PHILLIPS ST
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:
21225-3715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-269-3501
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2026