Provider First Line Business Practice Location Address:
648 RENZ 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:
19128-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-815-4568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2008