Provider First Line Business Practice Location Address: 
6615 REISTERSTOWN RD
    Provider Second Line Business Practice Location Address: 
SUITE 205A
    Provider Business Practice Location Address City Name: 
BALTIMORE
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21215-2686
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-486-2298
    Provider Business Practice Location Address Fax Number: 
410-358-6551
    Provider Enumeration Date: 
10/27/2006