Provider First Line Business Practice Location Address: 
196 THOMAS JOHNSON DR STE 100
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FREDERICK
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21702-4520
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
301-631-5748
    Provider Business Practice Location Address Fax Number: 
301-631-5750
    Provider Enumeration Date: 
06/28/2011