Provider First Line Business Practice Location Address:
3169 N 5TH 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:
19133-2823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-989-4455
Provider Business Practice Location Address Fax Number:
856-673-1905
Provider Enumeration Date:
01/12/2015