Provider First Line Business Practice Location Address:
2141 S 19TH 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:
19145-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-388-6380
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2025