Provider First Line Business Practice Location Address:
1817 NORTH 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:
19130-3308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-761-8522
Provider Business Practice Location Address Fax Number:
215-634-1422
Provider Enumeration Date:
08/04/2008