Provider First Line Business Practice Location Address:
163 E ALBANUS 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:
19120-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-639-8866
Provider Business Practice Location Address Fax Number:
215-525-0271
Provider Enumeration Date:
05/08/2026