Provider First Line Business Practice Location Address:
405 FREDERICK RD
Provider Second Line Business Practice Location Address:
STE 162
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-744-3553
Provider Business Practice Location Address Fax Number:
410-744-3586
Provider Enumeration Date:
10/25/2005