Provider First Line Business Practice Location Address:
1116 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:
19146-2837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-397-5450
Provider Business Practice Location Address Fax Number:
267-687-1978
Provider Enumeration Date:
10/28/2015