Provider First Line Business Practice Location Address:
2101 BRIGHTON 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:
19149-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-333-6611
Provider Business Practice Location Address Fax Number:
215-333-1820
Provider Enumeration Date:
09/21/2005