Provider First Line Business Practice Location Address:
766 S 4TH 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:
19147-3137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-922-2119
Provider Business Practice Location Address Fax Number:
215-922-2245
Provider Enumeration Date:
10/29/2010