Provider First Line Business Practice Location Address:
1209 S ELLWOOD 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:
21224-4914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-869-5303
Provider Business Practice Location Address Fax Number:
703-430-9785
Provider Enumeration Date:
03/10/2012