Provider First Line Business Practice Location Address:
1618 SOUTH 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:
19146-1542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-210-9877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2011