Provider First Line Business Practice Location Address:
1804 GREEN ST
Provider Second Line Business Practice Location Address:
UNIT #5
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19130-3968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-2261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2005