Provider First Line Business Practice Location Address:
6519 ROOSEVELT BLVD
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:
19149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-532-0657
Provider Business Practice Location Address Fax Number:
610-532-4258
Provider Enumeration Date:
08/30/2024