Provider First Line Business Practice Location Address:
1804 W NORTH 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:
21217-1621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-685-6331
Provider Business Practice Location Address Fax Number:
410-685-6332
Provider Enumeration Date:
07/18/2012