Provider First Line Business Practice Location Address:
624 N BROADWAY
Provider Second Line Business Practice Location Address:
HAMPTON HOUSE RM 249
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21205-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-502-9627
Provider Business Practice Location Address Fax Number:
410-502-6898
Provider Enumeration Date:
08/30/2007