Provider First Line Business Practice Location Address:
3655-A OLD COURT ROAD
Provider Second Line Business Practice Location Address:
SUITE # 7
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-486-9461
Provider Business Practice Location Address Fax Number:
410-486-1376
Provider Enumeration Date:
05/04/2007