Provider First Line Business Practice Location Address:
219 COLLINS 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:
21229-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-644-4002
Provider Business Practice Location Address Fax Number:
410-644-4003
Provider Enumeration Date:
12/21/2006