Provider First Line Business Practice Location Address:
5445 OAKLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-303-3512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2008