Provider First Line Business Practice Location Address: 
201 BOOTH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELKTON
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21921-5618
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-996-5449
    Provider Business Practice Location Address Fax Number: 
410-996-1062
    Provider Enumeration Date: 
02/20/2007