Provider First Line Business Practice Location Address:
1002 S DORRANCE 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:
19146-2651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-670-1948
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2026