Provider First Line Business Practice Location Address:
1435 69TH AVE
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:
19126-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-424-0135
Provider Business Practice Location Address Fax Number:
215-626-8938
Provider Enumeration Date:
10/08/2012