Provider First Line Business Practice Location Address:
2000 S 19TH 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:
19145-2813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-388-0068
Provider Business Practice Location Address Fax Number:
215-388-4618
Provider Enumeration Date:
01/13/2026