Provider First Line Business Practice Location Address:
854 N 13TH 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:
19123-1829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-763-6845
Provider Business Practice Location Address Fax Number:
267-687-5314
Provider Enumeration Date:
11/04/2009