Provider First Line Business Practice Location Address:
2200 CHELSEA TER
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:
21216-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-929-3436
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2025