Provider First Line Business Practice Location Address:
126 N LUZERNE 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:
21224-1147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-731-0400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2025