Provider First Line Business Practice Location Address:
5008 BALTIMORE AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19143-3302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-764-8520
Provider Business Practice Location Address Fax Number:
215-764-8521
Provider Enumeration Date:
05/03/2007