Provider First Line Business Practice Location Address:
4501 N CHARLES ST
Provider Second Line Business Practice Location Address:
ATHLETICS, M130
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21210-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-617-5276
Provider Business Practice Location Address Fax Number:
410-617-5709
Provider Enumeration Date:
02/07/2006