Provider First Line Business Practice Location Address:
6573 ROOSEVELT BLVD
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:
19149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-668-8001
Provider Business Practice Location Address Fax Number:
267-668-8002
Provider Enumeration Date:
07/13/2015