Provider First Line Business Practice Location Address:
2453 GRANT 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:
19114-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-437-9255
Provider Business Practice Location Address Fax Number:
215-941-7910
Provider Enumeration Date:
07/16/2010