Provider First Line Business Practice Location Address:
5047 BALTIMORE AVE FRNT
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:
19143-1698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-252-6128
Provider Business Practice Location Address Fax Number:
828-383-9667
Provider Enumeration Date:
04/14/2025