Provider First Line Business Practice Location Address:
4804 YORK ROAD, SUITE 2
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:
21212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-873-8958
Provider Business Practice Location Address Fax Number:
443-873-8959
Provider Enumeration Date:
11/09/2010