Provider First Line Business Practice Location Address:
4219 RIDGE 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:
19129-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-385-6024
Provider Business Practice Location Address Fax Number:
267-385-6238
Provider Enumeration Date:
11/08/2012