Provider First Line Business Practice Location Address:
4107 LIBERTY HEIGHTS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MARYLAND
Provider Business Practice Location Address Postal Code:
21207
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
410-542-5306
Provider Business Practice Location Address Fax Number:
410-542-0086
Provider Enumeration Date:
02/17/2016