Provider First Line Business Practice Location Address:
6904 RIDGE AVE
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:
19128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-483-8373
Provider Business Practice Location Address Fax Number:
215-483-1510
Provider Enumeration Date:
05/16/2008