Provider First Line Business Practice Location Address:
219 N KENWOOD 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:
21224-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-213-3309
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2025