Provider First Line Business Practice Location Address:
5411 OLD FREDERICK RD
Provider Second Line Business Practice Location Address:
SUITE 3, FREDERICK VILLA PROFESSIONAL CENTER
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-2195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-744-6565
Provider Business Practice Location Address Fax Number:
410-747-9948
Provider Enumeration Date:
07/30/2006