Provider First Line Business Practice Location Address:
1519 E NORTH 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:
21213-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-962-1617
Provider Business Practice Location Address Fax Number:
410-962-1512
Provider Enumeration Date:
10/30/2007