Provider First Line Business Practice Location Address:
19 E FAYETTE ST
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:
21202-6420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-625-1817
Provider Business Practice Location Address Fax Number:
410-625-4376
Provider Enumeration Date:
10/12/2011