Provider First Line Business Practice Location Address:
1526 NORTHBOURNE RD
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:
21239-3540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-935-8712
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2026