Provider First Line Business Practice Location Address:
6449 SPRAGUE 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:
19119-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-278-1494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2025