Provider First Line Business Practice Location Address:
6113 RIDGE AVE
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:
19128-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-482-2697
Provider Business Practice Location Address Fax Number:
215-482-8495
Provider Enumeration Date:
11/06/2006