Provider First Line Business Practice Location Address:
1621 RIDGE 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:
19130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-909-5510
Provider Business Practice Location Address Fax Number:
267-930-7587
Provider Enumeration Date:
08/03/2020