Provider First Line Business Practice Location Address:
4640 EDMONDSON 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:
21229-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-578-8003
Provider Business Practice Location Address Fax Number:
410-578-0029
Provider Enumeration Date:
08/16/2019