Provider First Line Business Practice Location Address:
1501 S EDGEWOOD ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21227-1071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-368-2825
Provider Business Practice Location Address Fax Number:
410-368-8449
Provider Enumeration Date:
07/29/2005