Provider First Line Business Practice Location Address:
201-109 BACK RIVER NECK RD
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-391-8733
Provider Business Practice Location Address Fax Number:
410-391-9630
Provider Enumeration Date:
07/01/2006