Provider First Line Business Practice Location Address: 
312 MARSHALL AVE
    Provider Second Line Business Practice Location Address: 
SUITE 102
    Provider Business Practice Location Address City Name: 
LAUREL
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
20707-4824
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-382-3771
    Provider Business Practice Location Address Fax Number: 
877-219-8773
    Provider Enumeration Date: 
11/19/2014