Provider First Line Business Practice Location Address:
641 N 22ND ST
Provider Second Line Business Practice Location Address:
APT 1F
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19130-3161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-356-0319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/01/2013