Provider First Line Business Practice Location Address:
2050 S. 58TH 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:
19143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-724-2218
Provider Business Practice Location Address Fax Number:
215-769-6952
Provider Enumeration Date:
05/04/2007