Provider First Line Business Practice Location Address:
4401 EASTERN AVENUE
Provider Second Line Business Practice Location Address:
BLDG 45 SUITE 2H
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-522-0884
Provider Business Practice Location Address Fax Number:
410-522-2712
Provider Enumeration Date:
11/18/2009