Provider First Line Business Practice Location Address:
3213 N 27TH 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:
19129-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-742-4163
Provider Business Practice Location Address Fax Number:
267-742-4163
Provider Enumeration Date:
07/14/2025