Provider First Line Business Practice Location Address:
4637 PARK HEIGHTS AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215-6331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-728-4491
Provider Business Practice Location Address Fax Number:
410-728-5942
Provider Enumeration Date:
02/09/2006