Provider First Line Business Practice Location Address:
1916 E CLEARFIELD 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:
19134-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-607-1073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2026