Provider First Line Business Practice Location Address:
540 S 48TH ST
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:
19143-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-235-9426
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2015