Provider First Line Business Practice Location Address:
1311 S 15TH 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:
19146-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-796-5180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2025