Provider First Line Business Practice Location Address:
619 N CARROLLTON AVE APT 1
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:
21217-3259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-744-5368
Provider Business Practice Location Address Fax Number:
443-744-5368
Provider Enumeration Date:
05/04/2026