Provider First Line Business Practice Location Address:
4119 ELLIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPITOL HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20743-5756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-219-8190
Provider Business Practice Location Address Fax Number:
877-219-8773
Provider Enumeration Date:
06/27/2012