Provider First Line Business Practice Location Address: 
1921 E BALTIMORE 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: 
21231-1902
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
443-869-2517
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/13/2007