Provider First Line Business Practice Location Address:
1551 N 29TH ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19121-3620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-572-8836
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2012