Provider First Line Business Practice Location Address:
1217 W FAYETTE ST
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:
21223-1938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-727-3947
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2020