Provider First Line Business Practice Location Address:
710 W CHAMPLOST ST
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:
19120-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-224-3227
Provider Business Practice Location Address Fax Number:
215-224-3227
Provider Enumeration Date:
10/17/2011