Provider First Line Business Practice Location Address:
818 E UPSAL 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:
19119-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-368-5108
Provider Business Practice Location Address Fax Number:
215-924-1264
Provider Enumeration Date:
03/09/2015