Provider First Line Business Practice Location Address:
835 E FORT 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:
21230-5117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-406-1517
Provider Business Practice Location Address Fax Number:
667-406-1526
Provider Enumeration Date:
02/23/2026