Provider First Line Business Practice Location Address:
1713 APPLETON ST
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:
21217-1133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-316-7513
Provider Business Practice Location Address Fax Number:
240-316-7513
Provider Enumeration Date:
06/14/2025