Provider First Line Business Practice Location Address: 
1600 CRAIN HWY S
    Provider Second Line Business Practice Location Address: 
SUITE 404
    Provider Business Practice Location Address City Name: 
GLEN BURNIE
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21061-5577
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-761-4442
    Provider Business Practice Location Address Fax Number: 
410-787-9647
    Provider Enumeration Date: 
07/02/2006