Provider First Line Business Practice Location Address:
4313 DISSTON ST
Provider Second Line Business Practice Location Address:
SUITE A, 1ST FLOOR
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19135-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-969-0999
Provider Business Practice Location Address Fax Number:
215-969-3343
Provider Enumeration Date:
04/29/2010