Provider First Line Business Practice Location Address:
1203 LAKESIDE 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:
21218-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-608-0401
Provider Business Practice Location Address Fax Number:
410-243-2246
Provider Enumeration Date:
04/25/2012