Provider First Line Business Practice Location Address:
5044 SPRUCE ST
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:
19139-4115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-294-6790
Provider Business Practice Location Address Fax Number:
215-474-4410
Provider Enumeration Date:
09/24/2013