Provider First Line Business Practice Location Address:
7622 OGONTZ 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:
19150-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-331-8417
Provider Business Practice Location Address Fax Number:
267-331-8461
Provider Enumeration Date:
09/13/2011