Provider First Line Business Practice Location Address:
621 N AUGUSTA AVE
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:
21229-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-938-6273
Provider Business Practice Location Address Fax Number:
443-835-1730
Provider Enumeration Date:
09/10/2026