Provider First Line Business Practice Location Address:
305 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 305 TATE CENTER
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-768-3701
Provider Business Practice Location Address Fax Number:
410-766-0881
Provider Enumeration Date:
04/20/2006