Provider First Line Business Practice Location Address:
1510 MIDVALE AVE
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:
21228-4334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-744-0472
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2006