Provider First Line Business Practice Location Address:
5407 N CHARLES STREET
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:
21210-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-433-8861
Provider Business Practice Location Address Fax Number:
410-433-1249
Provider Enumeration Date:
05/17/2006