Provider First Line Business Practice Location Address:
1242 S 20TH 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:
19146-4338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-977-0121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2023