Provider First Line Business Practice Location Address:
6210 PARK HEIGHTS AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-764-7341
Provider Business Practice Location Address Fax Number:
410-764-2638
Provider Enumeration Date:
05/12/2008