Provider First Line Business Practice Location Address:
2130 S 21ST 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:
19145-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-925-3566
Provider Business Practice Location Address Fax Number:
215-925-2990
Provider Enumeration Date:
05/25/2006