Provider First Line Business Practice Location Address:
32 N 50TH 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:
19139-2719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-426-7474
Provider Business Practice Location Address Fax Number:
555-555-5555
Provider Enumeration Date:
12/01/2025