Provider First Line Business Practice Location Address:
212 E GIRARD AVE
Provider Second Line Business Practice Location Address:
APT 2B
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19125-3917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-603-3009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2012