Provider First Line Business Practice Location Address:
5900 BALTIMORE AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19143-3129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-787-5700
Provider Business Practice Location Address Fax Number:
267-787-5711
Provider Enumeration Date:
12/09/2016