Provider First Line Business Practice Location Address:
4622 WILKENS 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:
21229-4842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-247-5802
Provider Business Practice Location Address Fax Number:
410-536-0646
Provider Enumeration Date:
07/09/2006