Provider First Line Business Practice Location Address:
1845 W NORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21217-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-369-6122
Provider Business Practice Location Address Fax Number:
443-438-7481
Provider Enumeration Date:
11/15/2010