Provider First Line Business Practice Location Address:
4623 FALLS ROAD
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:
21209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-366-1980
Provider Business Practice Location Address Fax Number:
410-366-8530
Provider Enumeration Date:
07/17/2006