Provider First Line Business Practice Location Address:
1628 GREEN 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:
19130-3910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-574-1319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2026