Provider First Line Business Practice Location Address:
2179 BENNETT RD
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19116-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-821-8238
Provider Business Practice Location Address Fax Number:
215-464-5666
Provider Enumeration Date:
01/05/2012