Provider First Line Business Practice Location Address:
1619 GRANT AVE STE 1
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:
19115-3162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-969-0082
Provider Business Practice Location Address Fax Number:
267-686-8606
Provider Enumeration Date:
06/04/2006