Provider First Line Business Practice Location Address:
10 N GREEN STREET
Provider Second Line Business Practice Location Address:
VISN 5 MIRECC SUITE 6A (BT/MIRECC)
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-605-7817
Provider Business Practice Location Address Fax Number:
410-605-7739
Provider Enumeration Date:
04/19/2006