Provider First Line Business Practice Location Address:
719 E PHIL ELLENA 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:
19119-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-429-8002
Provider Business Practice Location Address Fax Number:
267-297-7337
Provider Enumeration Date:
05/02/2012