Provider First Line Business Practice Location Address:
1508 W ERIE 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:
19140-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-236-2832
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2008