Provider First Line Business Practice Location Address:
3228 SOUTHERN 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:
21214-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-904-0091
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2025