Provider First Line Business Practice Location Address:
1244 S BUCKNELL 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:
19146-4135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-481-4257
Provider Business Practice Location Address Fax Number:
267-481-4257
Provider Enumeration Date:
02/12/2026