Provider First Line Business Practice Location Address:
1012 S 49TH 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:
19143-3406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-335-4872
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2012