Provider First Line Business Practice Location Address:
108 E BALTIMORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FUNKSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21734-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-401-2427
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2026