Provider First Line Business Practice Location Address:
4401 OLD YORK RD
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:
21212-4815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-501-9945
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2026