Provider First Line Business Practice Location Address:
5501 WOODLAND 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:
19143-5607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-729-3912
Provider Business Practice Location Address Fax Number:
215-729-3916
Provider Enumeration Date:
11/15/2011