Provider First Line Business Practice Location Address:
5125 N SYDENHAM 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:
19141-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-265-1278
Provider Business Practice Location Address Fax Number:
267-389-2785
Provider Enumeration Date:
09/05/2025