Provider First Line Business Practice Location Address:
2129 W OREGON AVE
Provider Second Line Business Practice Location Address:
FIRST FLOOR REAR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-462-6106
Provider Business Practice Location Address Fax Number:
215-462-5922
Provider Enumeration Date:
05/22/2006