Provider First Line Business Practice Location Address: 
1447 YORK RD
    Provider Second Line Business Practice Location Address: 
SUITE 312
    Provider Business Practice Location Address City Name: 
LUTHERVILLE
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21093-6017
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-583-7021
    Provider Business Practice Location Address Fax Number: 
410-828-8789
    Provider Enumeration Date: 
03/11/2013