Provider First Line Business Practice Location Address:
1214 MOORE 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:
19148-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-577-2182
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2008