Provider First Line Business Practice Location Address:
6237 SPRUCE STREET
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:
19139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-714-1944
Provider Business Practice Location Address Fax Number:
215-714-1945
Provider Enumeration Date:
07/28/2026