Provider First Line Business Practice Location Address:
37 W BALTIMORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FUNKSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21734-1163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-643-8768
Provider Business Practice Location Address Fax Number:
888-443-7441
Provider Enumeration Date:
08/19/2025