Provider First Line Business Practice Location Address:
519 W PRATT ST APT 609
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:
21201-0442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-217-9578
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2025