Provider First Line Business Practice Location Address:
4812 DISSTON 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:
19135-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-359-1144
Provider Business Practice Location Address Fax Number:
215-501-5151
Provider Enumeration Date:
04/01/2009