Provider First Line Business Practice Location Address:
6565 N CHARLES ST
Provider Second Line Business Practice Location Address:
PPE# 211
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-849-2369
Provider Business Practice Location Address Fax Number:
443-849-2248
Provider Enumeration Date:
10/14/2011