Provider First Line Business Practice Location Address:
1531 S EDGEWOOD ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
HALETHORPE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21227-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-458-5854
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2013