Provider First Line Business Practice Location Address: 
2514 GREENMOUNT AVENUE
    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: 
21218
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
833-224-5483
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/27/2020