Provider First Line Business Practice Location Address:
5636 N 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:
19141-1104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
835-235-7981
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2026