Provider First Line Business Practice Location Address:
5200 EASTERN AVENUE
Provider Second Line Business Practice Location Address:
3RD FLOOR, ROOM 326 MASON LORD BUILDING
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-550-0530
Provider Business Practice Location Address Fax Number:
410-550-0491
Provider Enumeration Date:
05/23/2012