Provider First Line Business Practice Location Address:
1605 W ALLEGHENY AVE
Provider Second Line Business Practice Location Address:
APT 203
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19132-3239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-340-5145
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2010