Provider First Line Business Practice Location Address:
1119 LIGHT 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:
21230-4104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-752-5810
Provider Business Practice Location Address Fax Number:
410-727-5403
Provider Enumeration Date:
09/30/2006