Provider First Line Business Practice Location Address: 
4015 LABYRINTH RD
    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: 
21215-1416
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-764-2501
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/08/2008