Provider First Line Business Practice Location Address:
6317 WALLIS 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:
21215-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-358-0777
Provider Business Practice Location Address Fax Number:
410-318-8310
Provider Enumeration Date:
06/08/2007