Provider First Line Business Practice Location Address:
1624 N ELLAMONT ST
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:
21216-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-362-2790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2023