Provider First Line Business Practice Location Address:
1429 GERMANTOWN AVE UNIT 3A
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:
19122-3784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-389-3480
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2026