Provider First Line Business Practice Location Address:
22 SOUTH GREEN STREET, ROOM N3E09
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:
21201-1595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-1142
Provider Business Practice Location Address Fax Number:
410-328-0267
Provider Enumeration Date:
05/10/2021