Provider First Line Business Practice Location Address:
4240 CHIPPENDALE 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:
19136-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-332-4176
Provider Business Practice Location Address Fax Number:
215-332-4176
Provider Enumeration Date:
01/28/2009