Provider First Line Business Practice Location Address:
633 E MOUNT AIRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19119-1147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-242-1204
Provider Business Practice Location Address Fax Number:
215-248-1249
Provider Enumeration Date:
05/15/2008